Pregnancy outcome of threatened abortion with demonstrable fetal cardiac activity: a cohort study

Long-term risk of epilepsy, cerebral palsy and attention-deficit/hyperactivity disorder in children affected by a threatened abortion in utero

BACKGROUND

The birth of a child affected by a threatened abortion (TAB) in utero is associated with autism spectrum disorder; association with other neurological disorders is unknown.

METHODS

This nationwide registry-based cohort study included singletons live-born in Denmark (1979-2010), followed through 2016. The outcomes were epilepsy, cerebral palsy (CP) and attention-deficit/hyperactivity disorder (ADHD). We used Cox regression to compute hazard ratios (HRs), adjusted for birth year, birth order, parental age, morbidity, medication use and maternal socio-economic factors. To remove time-invariant family-shared confounding, we applied sibling analyses.

RESULTS

The study population included 1 864 221 singletons live-born in 1979-2010. Among the TAB-affected children (N = 59 134) vs TAB-unaffected children, at the end of follow-up, the cumulative incidence was 2.2% vs 1.6% for epilepsy, 0.4% vs 0.2% for CP and 5.5% vs 4.2% for ADHD (for children born in 1995-2010). The adjusted HRs were 1.25 [95% confidence interval (CI) 1.16-1.34] for epilepsy, 1.42 (95% CI 1.20-1.68) for CP and 1.21 (95% CI 1.14-1.29) for ADHD. In the sibling design, the adjusted HRs were unity for epilepsy (full siblings: 0.96, 95% CI 0.82-1.12; maternal: 1.04, 95% CI 0.90-1.20; paternal: 1.08, 95% CI 0.93-1.25) and ADHD (full: 1.08, 95% CI 0.92-1.27; maternal: 1.04, 95% CI 0.90-1.20; paternal: 1.08, 95% CI 0.93-1.25). For CP, HRs shifted away from unity among sibling pairs (full: 2.92, 95% CI 1.33-6.39; maternal: 2.03, 95% CI 1.15-3.57; paternal: 3.28, 95% CI 1.36-7.91).

CONCLUSIONS

The birth of a child affected by TAB in utero was associated with a greater risk of CP, but not epilepsy or ADHD.

Early-pregnancy events and subsequent antenatal, delivery and neonatal outcomes: prospective cohort study

OBJECTIVE

To assess prospectively the association between pelvic pain, vaginal bleeding, and nausea and vomiting occurring in the first trimester of pregnancy and the incidence of later adverse pregnancy outcomes.

METHODS

This was a prospective observational cohort study of consecutive women with confirmed intrauterine singleton pregnancy between 5 and 14 weeks' gestation recruited at Queen Charlotte's & Chelsea Hospital, London, UK, from March 2014 to March 2016. Serial ultrasound scans were performed in the first trimester. Participants completed validated symptom scores for vaginal bleeding, pelvic pain, and nausea and vomiting. The key symptom of interest was any pelvic pain and/or vaginal bleeding during the first trimester. Pregnancies were followed up until the final outcome was known. Antenatal, delivery and neonatal outcomes were obtained from hospital records. Logistic regression analysis was used to assess the association between first-trimester symptoms and pregnancy complications by calculating adjusted odds ratios (aOR) with correction for maternal age.

RESULTS

Of 1003 women recruited, 847 pregnancies were included in the final analysis following exclusion of cases due to first-trimester miscarriage (n = 99), termination of pregnancy (n = 20), loss to follow-up (n = 32) or withdrawal from the study (n = 5). Adverse antenatal complications were observed in 166/645 (26%) women with pelvic pain and/or vaginal bleeding in the first trimester (aOR = 1.79; 95% CI, 1.17-2.76) and in 30/181 (17%) women with no symptoms. Neonatal complications were observed in 66/634 (10%) women with and 11/176 (6%) without pelvic pain and/or vaginal bleeding (aOR = 1.73; 95% CI, 0.89-3.36). Delivery complications were observed in 402/615 (65%) women with and 110/174 (63%) without pelvic pain and/or vaginal bleeding during the first trimester (aOR = 1.16; 95% CI, 0.81-1.65). For 18 of 20 individual antenatal complications evaluated, incidence was higher among women with pelvic pain and/or vaginal bleeding, despite the overall incidences being low. Nausea and vomiting in pregnancy showed little association with adverse pregnancy outcomes.

CONCLUSIONS

Our study suggests that there is an increased incidence of antenatal complications in women experiencing pelvic pain and/or vaginal bleeding in the first trimester. This should be considered when advising women attending early-pregnancy units. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Fetal Growth Patterns in Pregnancies With First-Trimester Bleeding

OBJECTIVE

To assess the relationship between first-trimester vaginal bleeding and fetal growth patterns.

METHODS

We conducted a secondary analysis of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Fetal Growth Studies-Singletons, a prospective cohort study of low-risk, nonobese women with healthy lifestyles. Duration of bleeding was self-reported at enrollment (10 0/7 to 13 6/7 weeks of gestation) and categorized as 0, 1, or more than 1 day. Longitudinal measures of fetal biometrics were obtained in up to six study visits, and estimated fetal weight was computed. Growth trajectories were created for biometrics and estimated fetal weight. When global tests among groups was significant (P<.05), week-specific global and pairwise differences were tested. Birth weight and risk of a small-for-gestational-age (SGA) neonate were secondary outcomes. All analyses were adjusted for maternal age, weight, height, parity, and racial-ethnic group and neonatal sex in a sensitivity analysis.

RESULTS

In 2,307 eligible women, 410 (17.8%) reported first-trimester bleeding, of whom 176 bled for 1 day and 234 bled for more than 1 day. Women with more than 1 day of bleeding demonstrated decreased fetal abdominal circumference from 34 to 39 weeks of gestation compared with women without bleeding. For women with more than 1 day of bleeding, compared with women without bleeding, estimated fetal weight was 68-107 g smaller from 35 to 39 weeks of gestation. Mean birth weight at term was 88 g smaller, confirming differences in calculated fetal weight, and SGA neonates were delivered to 148 (8.5%), 9 (5.7%), and 33 (15.7%) women in the no bleeding, 1 day, and more than 1 day of bleeding groups, respectively.

CONCLUSION

More than 1 day of first-trimester vaginal bleeding was associated with smaller estimated fetal weight late in pregnancy driven by smaller abdominal circumference. The magnitude of decrease in birth weight was small, albeit comparable with observed decreases associated with maternal smoking. It remains unknown whether early pregnancy bleeding is associated with short-term or long-term morbidity and whether additional intervention would be of benefit.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT00912132.

Obstetric outcomes of patients with abortus imminens in the first trimester

PURPOSE

We aimed to find out the effect of abortus imminens (AI) on obstetric outcomes of pregnancies which continued beyond the 24th week of gestation.

METHODS

In this prospective study, 309 patients with AI were divided into high-risk group (with a risk factor for spontaneous abortus) (n = 92) and low-risk group (without a risk factor) (n = 217). The control group (n = 308) was chosen randomly.

RESULTS

In AI group, preterm delivery, preterm premature rupture of membranes (PPROM), cesarean section (C/S) delivery, postpartum uterine atony and need of a neonatal intensive care unit (NICU) rates were significantly higher than control group. Gestational diabetes mellitus, PPROM, still birth, low APGAR scores were seen more frequently in the high-risk patients than in the control group. Furthermore in the high-risk group, preterm delivery, malpresentation, C/S delivery and need of NICU were increased much more than in the low-risk group. Gestational hypertension/preeclampsia, oligo/polyhydramniosis, intrauterine growth retardation, placenta previa, abruption of placenta, chorioamnionitis, congenital abnormalities, delivery induction, cephalopelvic disproportion, fetal distress and manual removal of placenta were not different among the groups.

CONCLUSIONS

Patients with AI history, especially with high-risk factors can have adverse obstetric and neonatal results. So their antenatal follow-up has to be done cautiously for the early signs and symptoms of these complications.

Pregnancy outcome in women with threatened miscarriage: a year study

Introduction:

Patients with threatened miscarriage associated with adverse pregnancy outcomes because of associated pregnancy and labor complications.

Objectives:

To evaluate the effect of threatened miscarriage on early and late pregnancy outcome.

Methods:

A retrospective case–controlled study was performed on 89 women with threatened miscarriage (study group) at Maternity and Children Hospital Buraidah, KSA from January 2010 to December 2010. They were matched for age and parity to 45 cases (control group) attending route antenatal clinic at the same time. Data recorded included, demographic characteristics and detailed pregnancy outcome and ultrasound finding including gestational age, cardiac activity and subchorionic hematoma.

Results:

The overall adverse pregnancy outcome was significantly higher in the studied cases compared to the control group (p=015).The miscarriage rate was significantly higher in study group compared to the controls group, (16.9%vs 2.2%, p=0000). Preterm delivery, babies with low birth weight and premature rupture of membranes were significantly higher in the miscarriage group compared to the controls group, (15.7% vs 2.2%, p=0.001), (15.7% vs 2.2%), p=0.001) and (6.7%) vs 4.45), p=0.016). There were no significant differences in other pregnancy outcomes.

Conclusion:

threatened miscarriage is associated with increased incidence of adverse pregnancy outcome. The risk is specially increased in premature rupture of the membranes, preterm delivery and neonatal birth weight.

A systematic review of dydrogesterone for the treatment of threatened miscarriage

The objective of this systematic review was to assess whether the orally acting progestagen, dydrogesterone lowers the incidence of miscarriage in women with threatened miscarriage. A computerized search was performed in Medline, Embase, and Ovid Medline for original reports with the product name 'Duphaston' or 'dydrogesterone', and limited to clinical human data. Twenty-one reports of dydrogesterone treatment were identified with 1380 patients. Five randomized trials were identified, including 660 women who fulfilled the criteria for meta-analysis. The number of subsequent miscarriages or continuing pregnancies per randomized woman was compared in women receiving dydrogesterone compared to standard bed rest or placebo intervention. There was a 13% (44/335) miscarriage rate after dydrogesterone administration compared to 24% in control women [odds ratio for miscarriage 0.47, (CI = 0.31-0.7), 11% absolute reduction in the miscarriage rate]. The adverse and side effects were summarized in all 21 reports, and seemed to be minimal. Although all the predictive and confounding factors could not be controlled for, the results of this systematic review show a significant reduction of 47% in the odds for miscarriage when dydrogesterone is compared to standard care indicating a real treatment effect.

Pro- and antiinflammatory cytokines in threatened miscarriages

OBJECTIVE

The purpose of this study was to evaluate circulating and intracellular levels of Th1 and Th2 cytokines in women with threatened miscarriage (TM) and subsequent outcome.

STUDY DESIGN

Plasma levels of tumor necrosis factor (TNF)-receptors 1 and 2, TNFα, interferon gamma (IFNγ), and interleukins (IL) -6 and -10 were measured by flow cytometric bead assays in 80 women with TM: 53 women with normal outcome and 27 women who miscarried. Fluorescent antibody labeling was also performed on whole blood in a subgroup of 27 women of TM: 16 women with normal outcome and 11 women who miscarried.

RESULTS

Monocyte expression of TNFα and circulating levels of TNFα, IFNγ, IL-10, IL-6, and TNF-R1 were significantly lower, whereas circulating levels of TNFα/IL-10, IFNγ/IL-10, and TNFα/IL-6 ratios were significantly higher, in women with TM who subsequently miscarried, compared with the women with normal outcome.

CONCLUSION

An increased Th1 type of immune response, which was similar to that observed in preterm delivery, was found in TM cases that were complicated by a subsequent miscarriage.

Vaginal bleeding in early pregnancy and preterm birth: systemic review and analysis of heterogeneity

OBJECTIVE

To systemically review published studies of vaginal bleeding and the risk of preterm birth (PTB) and explore sources of heterogeneity between them.

METHODS

The literature was searched for peer-reviewed articles from 1980 to 2009 in which the primary analysis was the risk of PTB among low-risk subjects with and without bleeding. Heterogeneity was assessed through I(2) statistics, and sources of heterogeneity were explored through subgroup analyses and meta-regression.

RESULTS

218 studies were initially identified, 64 reviewed and 23 included. The pooled Odds Ratio for PTB was 1.74, though significant heterogeneity was present (I(2)  =  49.7%). Meta-regression demonstrated a significant association between a study's incidence of bleeding and quality assessment and subsequent odds ratio, such that studies with a lower quality assessment or lower incidence of bleeding demonstrated an increased odds of PTB.

CONCLUSIONS

Bleeding in early pregnancy is associated with an increased risk of PTB; however, excessive heterogeneity exists among published studies. The heterogeneity arises in part from differences in the reported incidence of bleeding within study populations. Presumably studies that identify bleeding in a larger percentage of subjects consequently dilute the magnitude of the risk.

Obstetric outcome and cytokine levels in threatened miscarriage

OBJECTIVES

To evaluate the proportion of women with threatened miscarriage (TM) who proceed to miscarriage in a population of single ethnicity and to investigate prospectively their risk of adverse pregnancy outcome in relationship with the cytokines levels in their circulation.

METHODS

We conducted a prospective observational study over a period of 1 year of 94 Maltese women presenting with TM at the same hospital and compared their clinical data with those of 564 age-matched controls from the National Obstetric Information System (NOIS) of Malta. Main outcome measures included gestational age and weight at delivery and incidence of adverse pregnancy outcomes. A pilot study was carried out, where in subgroups of 10 women with TM (n=10), non-pregnant women (n=12), normal pregnant controls (n=9) and women presenting with missed-miscarriage (n=11), the plasma levels of β-human chorionic gonadotrophin (β-hCG), tumour necrosis factor α (TNFα), interferon γ (IFNγ), interleukin-6 (IL-6), interleukin-10 (IL-10) and TNF-receptors 1 (R1) and 2 (R2) were measured.

RESULTS

Of the women presenting with TM, 25 (26.6%) proceeded to complete miscarriage. The TM group had also a significantly higher incidence of antepartum haemorrhage (p<0.005), pre-eclampsia (p<0.05), foetal growth restriction (p<0.05), premature labour (p<0.001) and retained placenta (p<0.005). In the pilot biochemical analysis, significantly (p<0.05) higher levels of TNFα and lower levels of TNFR2 were found in the TM subgroup compared to non-pregnant controls. The ratio TNFα/IL-10 was significantly (p<0.05) higher and the β-hCG levels was significantly lower (p<0.01) in missed-miscarriage and non-pregnant subgroups than in TM and normal pregnant controls. The IFNγ/1L-10 and IFNγ/1L-6 ratio were significantly (<0.001) different between the four subgroups with the lowest level found in TM. No similar gradient was found for the TNFα/1L-6 ratio.

CONCLUSION

Women presenting with TM are at significantly increased risk of adverse pregnancy outcome and the pathophysiology of these conditions involves a change in the Th1/Th2 balance. Changes in levels of cytokines could help to predict and thus prevent the development of some of these complications.

Fetal loss in threatened abortion after demonstration of fetal cardiac activity in a low socioeconomic population

This study was conducted to determine the incidence and risk factors of fetal loss in threatened abortion after ultrasonographic detection of fetal cardiac activity in a low socioeconomic population. A total of 202 women with singleton pregnancies who presented with vaginal bleeding in which fetal heart activity was ultrasonographically demonstrated between 5 and 14 weeks' gestation were included. Pregnancies with fetal abnormalities were excluded from the study. All cases were followed-up with respect to pregnancy outcomes. A total of 54 of 202 pregnancies (26.7%) resulted in fetal loss before 20 weeks' gestation. The mean fetal heart rate (FHR) and cervical length values were lower in spontaneous abortions than in viable pregnancies (121.2 +/- 13.3 vs 143.5 +/- 12.4 and 41 +/- 6.0 vs. 34.8 +/- 6.1, respectively; p < 0.001). A receiver operating characteristic (ROC) curve analysis revealed an area under the curve of 0.88 for FHR and 0.77 for cervical length. A FHR value <130 b.p.m. was 81.4% sensitive, 85.1% specific and a cervical length value <40 mm was 80.8% sensitive, 54.7% specific for determination of fetal loss before 20 weeks' gestation. Fetal loss was observed in about one-quarter of pregnancies admitted with threatened abortion in a low socioeconomic population. Bradycardia and short cervix were found to be significant risk factors affecting the pregnancy outcome in women presenting with vaginal bleeding, in whom fetal cardiac activity was documented.

A comparison between the pregnancy outcome in women both with or without threatened abortion

OBJECTIVE

To evaluate the pregnancy outcome in pregnancies with threatened abortion (miscarriage).

MATERIAL AND METHOD

A prospective cohort study was performed on 1000 pregnant women. 500 women (case group), had a history of vaginal bleeding during the first half of pregnancy and the other 500 women (control group), did not have this history. Both groups of women were monitored from 20 weeks of pregnancy up to delivery.

RESULTS

The women of the 2 groups did not have any significant differences according to age, parity or body mass index (BMI). Spontaneous preterm delivery [126 cases (25.2%) vs. 47 cases (9.4%), P=0.001, adj RR=1.4, CI 95%=1.2-1.5], PROM [51 cases (10.2%) vs. 24 cases (4.8%), P=0.02, adj RR=2.1, CI95%=1.2-2.3], placental abruption [20 cases (4%) vs. 7 cases (1.4%) P=0.01, adj RR=1.1, CI 95%=1.01-1.2], were more in the case group. There were no differences between the 2 groups with regard to Preeclampsia, small for gestational age (SGA), and cesarean deliveries. Neonatal weight (in term pregnancies) in the case group was lower than in the control group (3046.4+/-560.8 g vs. 3317.6+/-432 g, P=0.001). There was a significant relationship between the number of bleeding episodes, spontaneous preterm delivery and placental abruption and there was also a significant relationship between the amount of bleeding and placental abruption.

CONCLUSION

Threatened abortion increases the rate of spontaneous preterm delivery, PROM and placental abruption, and decreases the neonatal weight. Therefore threatened abortion indicates a high risk pregnancy and, as such, demands more serious prenatal care.

Association between first-trimester vaginal bleeding and miscarriage

OBJECTIVE

To estimate the strength of association between first-trimester bleeding and miscarriage, setting aside bleeding at time of loss.

METHODS

Women enrolled in a community-based pregnancy cohort study before or during early pregnancy. Detailed first-trimester bleeding data were collected by telephone interview. Bleeding episodes proximal to miscarriage (within 4 days) were excluded. We used discrete-time hazard models to evaluate the association between bleeding and miscarriage. Models were adjusted for maternal age, prior miscarriage, and smoking. Exploratory regression tree analysis was used to evaluate the relative importance of other bleeding characteristics (duration, associated pain, color, timing).

RESULTS

Of the 4,510 participants, 1,204 (27%) reported some first-trimester vaginal bleeding or spotting, and 517 miscarriages were observed. Eight percent of those with bleeding reported heavy bleeding episodes. When we evaluated any bleeding, including episodes of only spotting, the unadjusted relative odds ratio (OR) of miscarriage for women with bleeding (n=1,204) was 1.1 (95% confidence interval [CI] 0.9-1.3). However, women who reported heavy bleeding (n=97) had nearly three times the risk of miscarriage compared with women without bleeding during the first trimester (OR 3.0, 95% CI 1.9-4.6). Adjustment for covariates had little effect on estimates. Further analyses suggested that women with heavy bleeding accompanied by pain were the group accounting for most of the elevated risk.

CONCLUSION

Heavy bleeding in the first trimester, particularly when accompanied by pain, is associated with higher risk of miscarriage. Spotting and light episodes are not, especially if lasting only 1-2 days.

LEVEL OF EVIDENCE

II.

Prediction of outcome in women with symptomatic first-trimester pregnancy: focus on intrauterine rather than ectopic gestation

OBJECTIVE

Symptoms of vaginal bleeding and abdominal pain are common in cases of ectopic pregnancy (EP), spontaneous abortions (SAB), and complications of an intrauterine pregnancy (IUP). It is important to determine if efforts should focus on differentiating EP from an IUP (IUP + SAB) or a viable IUP from a nonviable gestation (EP + SAB) in women at risk for EP.

METHODS

This is a retrospective cohort study of women who presented with bleeding or pain or both during the first trimester of pregnancy. The cohort was divided into subjects diagnosed with IUP vs. (EP + SAB). The same cohort was then divided into subjects diagnosed with EP vs. (IUP + SAB). Logistic regression models based on risk factors for both outcomes (EP vs. [IUP + SAB] and IUP vs. [EP + SAB]) were obtained. ROC curves as well as Hosmer-Lemeshow goodness of fit and Akaike's information criterion (AIC) were used.

RESULTS

Overall, 18.1% (n = 367) of the women were diagnosed with EP, 58.8% (n = 1192) were diagnosed with an SAB, and 23.1% (n = 467) had an ongoing IUP. The area under the ROC curve for the model IUP vs. (EP + SAB) was statistically greater than the model EP vs. (IUP + SAB), p < 0.001. AIC and Hosmer-Lemeshow goodness of fit confirmed the better accuracy of the model comparing IUP vs. (EP + SAB).

CONCLUSIONS

Information collected at initial presentation from women at risk for EP to be used for building prediction rules should focus on differentiating a viable from a nonviable pregnancy rather than attempting to distinguish an extrauterine from an intrauterine pregnancy. However, this distinction should not affect current clinical care.

Evidence of early first-trimester growth restriction in pregnancies that subsequently end in miscarriage

OBJECTIVES

To examine whether viable early pregnancies that subsequently end in miscarriage exhibit evidence of first-trimester growth restriction.

DESIGN

Prospective cohort study.

SETTING

Early pregnancy unit (EPU) of a teaching hospital.

POPULATION

Women attending EPU between 5 and 10 weeks of gestation.

METHODS

Women with spontaneously conceived intrauterine, viable singleton pregnancies with certain last menstrual period and regular cycles were included. The deviation between the observed and expected crown-rump length (CRL) for gestation was calculated and expressed as a z score. Pregnancies were followed up until the 11-14 week scan, and the deviation between those that remained viable and miscarried subsequently was calculated.

MAIN OUTCOME MEASURES

Viability at 11-14 week scan.

RESULTS

Over 6 months, 316 women met the inclusion criteria. Twenty-four (7.4%) women were excluded. Of the remaining 292, the pregnancy remained viable in 251 (86%) and 41 (14%) suffered a miscarriage. At the first transvaginal ultrasound, the z score of the mean measured CRL for pregnancies that remained viable was -0.82, SD 1.46, while in pregnancies that subsequently miscarried the z score was -2.42 and the CRL was significantly smaller, SD 1.31 (P < 0.0001). In the latter group, the initial CRL was below the expected mean for gestational age in all women, while in 61% (25/41), the CRL was at least 2 SDs below the expected mean.

CONCLUSIONS

CRL was significantly smaller in pregnancies that subsequently ended in miscarriage. This suggests that early first-trimester growth restriction is associated with subsequent intrauterine death.

Maternal serum hormone concentrations for prediction of adverse outcome in threatened miscarriage

Many serum markers have been investigated in attempts to predict the outcome of pregnancy in the first trimester, with varying degrees of success. The objective of this study was to investigate whether they can be related to pregnancy outcome in women presenting with first trimester threatened miscarriage. A cohort study of women attending the Early Pregnancy Unit of a London teaching hospital was studied. A total of 122 women presenting with bleeding in the first trimester and an ongoing pregnancy, and 33 women undergoing termination of pregnancy, were recruited. The main outcome measures were gestation at delivery, birth weight and the incidence of adverse pregnancy outcome. Inhibin A, activin A, human chorionic gonadotrophin (HCG), pregnancy-associated plasma protein-A and follistatin concentrations were all significantly lower in women who subsequently miscarried when compared with live births. Serum HCG concentrations were significantly higher in cases of threatened miscarriage compared with controls (P = 0.0009). Logistic regression analysis indicated that inhibin A alone provided the best predictor for first trimester miscarriage. This pilot study suggests that placental hormone concentrations could be useful in predicting adverse pregnancy outcome in women presenting with threatened miscarriage. Inhibin A was best at predicting the likelihood of subsequent miscarriage in this group.

Emergency gynaecology

The management of gynaecological emergencies is directed at the preservation of life, health, sexual function and the perpetuation of fertility. Ectopic pregnancy (EP), pelvic inflammatory disease (PID) and miscarriages are common gynaecological emergencies and early recognition and appropriate treatment is essential to avoid unwanted sequelae. Controversy will always exist in clinical medicine because management is mainly based on uncontrolled studies, expert opinion and personal experiences. It is estimated that only 10% of clinical treatments have been validated by prospective, randomised trials. Recent advances have led to earlier diagnosis and more conservative treatment on an outpatient or day care basis in EP and miscarriages.

Vaginal bleeding in the first 20 weeks of pregnancy

The first and foremost diagnosis to exclude in the pregnant patient presenting with vaginal bleeding is ectopic pregnancy. Once ectopic pregnancy is ruled out, miscarriage should be considered as a clinical spectrum. Its management is directed according to the integrity of the internal cervical os and patient hemodynamic status. Treatment with anti-D immune globulin is warranted for all Rh-negative patients. Urgent obstetric consultation is necessary for most miscarriage presentations.

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.

Midwifery management of first trimester bleeding and early pregnancy loss

As many as 25% of women experience bleeding in the first and early second trimester of pregnancy; about half of these will have a miscarriage or, more rarely, ectopic or molar pregnancy loss. This can be a difficult time for women because of the uncertainty of the outcome, lack of preventative measures, and emotional significance of early pregnancy loss. The qualities that characterize midwifery care, including providing complete information, encouraging self-determination, and being sensitive to the emotional state, are particularly important at this time. This article reviews the epidemiology; physiologic process; signs and symptoms of first trimester bleeding; miscarriage and other early pregnancy losses; and methods of clinical, biochemical, and sonographic evaluation. A framework to guide midwifery evaluation and management, based on confirmation of an intrauterine pregnancy followed by the determination of viability, is presented. Surgical, medical, and expectant management of nonviable pregnancy, management of viable pregnancy when bleeding persists, and follow-up care, including screening for psychological sequelae, are discussed. Case studies and specific clinical guidelines for midwifery care, consultation, collaboration, and referral are included. Understanding the emotional significance of first trimester bleeding and loss as a basis for sensitive care throughout the management process is addressed.