Threatened abortion: prediction of viability based on signs and symptoms

[Pelvic exam in gynecology and obstetrics: Guidelines for clinical practice]

OBJECTIVE

To provide guidelines for the pelvic clinical exam in gynecology and obstetrics.

MATERIAL AND METHODS

A multidisciplinary experts consensus committee of 45 experts was formed, including representatives of patients' associations and users of the health system. The entire guidelines process was conducted independently of any funding. The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The committee studied 40 questions within 4 fields for symptomatic or asymptomatic women (emergency conditions, gynecological consultation, gynecological diseases, obstetrics, and pregnancy). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 27 recommendations. Among the formalized recommendations, 17 present a strong agreement, 7 a weak agreement and 3 an expert consensus agreement. Thirteen questions resulted in an absence of recommendation due to lack of evidence in the literature.

CONCLUSIONS

The need to perform clinical examination in gynecological and obstetrics patients was specified in 27 pre-defined situations based on scientific evidence. More research is required to investigate the benefit in other cases.

Candidate Circulating Biomarkers of Spontaneous Miscarriage After IVF-ET Identified via Coupling Machine Learning and Serum Lipidomics Profiling

Spontaneous miscarriage is a common pregnancy complication. Multiple etiologies have been proposed such as genetic aberrations, endocrinology disorder, and immunologic derangement; however, the relevance of circulating lipidomes to the specific condition remains unclear. In the present study, lipidomics profiling was examined on serum of women with spontaneous miscarriage after in vitro fertilization and embryo transfer (IVF-ET). Screening and analysis of differential lipid levels were conducted using a machine learning approach to verify the stability and validity of potential serum biomarkers. Seven lipid species presented significant differences between the abortion and term birth patients, including three types of sphingomyelins (SMs), two types of diglycerides (DGs), one phosphatidylcholine (PC), and one lysophosphatidylethanolamine (LPE). All the SMs presented with a fold change of > 1, while both the PC and LPE had a fold change of < 1. The DG containing two saturated fatty acyl chains was decreased, but that containing two unsaturated fatty acyl chains was increased in the miscarriage group compared to the control group. This study reveals the relevance of lipid profiles to spontaneous abortion after IVF-ET, providing potential biomarkers and therapeutic targets for the specific clinical scenario.

Influence of threatened miscarriage on pregnancy and early postpartum period: a case-control report

OBJECTIVE

To evaluate the influence of threatened miscarriage on obstetric complications during pregnancy and early postpartum period.

METHODS

In this case-control study, hospital records of 12,050 first-trimester patients between January 2011 and December 2012 at the Research and Educational Hospital in Ankara, Turkey, were used. Of the 12,050 patients, 481 threatened miscarriage patients were evaluated. The control group was formed by age- and body mass index-matched cases without first trimester bleeding. Abortion, intrauterine foetal demise, preterm birth, preeclampsia, antenatal haematoma, uterine atony placental abruption and low birth-weights were compared between the study and the control group.

RESULTS

When compared with the control group, the risk of having a preterm birth (p = 0.014; OR: 1.95; 95% CI: 1.15-3.24), low-birth-weight infant (p = 0.001; OR: 2.33; 95% CI: 1.45-3.83) and abortion (p = 0.00; OR: 2.55; 95% CI: 1.62-3.91) increased in cases of threatened miscarriage. However, the risk of uterine atony was decreased (p = 0.006; OR: 0.09; 95% CI: 0.12-0.7) in the threatened miscarriage group when compared with the control group. Threatened miscarriage did not increase the risk of placenta praevia, placental abruption or intrauterine foetal demise.

CONCLUSION

Increased complications after threatened miscarriage is probably due to the persistence of a triggering mechanism. As preterm birth and abortion rate increased, whilst uterine atony rate decreased, one of the mechanisms causing threatened miscarriage might be increased uterine contractility.

Association between first trimester vaginal bleeding and uterine artery Doppler measured at second and third trimesters of pregnancy

OBJECTIVE

To evaluate the prevalence of first trimester vaginal bleeding among patients with abnormal second and third trimester uterine artery Doppler.

METHODS

A prospective study of patients with a uterine artery Doppler measurement between 27 and 42 weeks' gestation was undertaken. A comparison was made between two groups: patients with and without first trimester vaginal bleeding. Abnormal uterine artery Doppler was defined as PI >95th% or the presence of a diastolic notch.

RESULTS

Of the 277 patients that were included in the study, 65 (23%) had first trimester vaginal bleeding. No differences were noted in uterine artery Doppler waveforms among patients with and without first trimester vaginal bleeding. Among patients with first trimester vaginal bleeding, 9 (14%) had a bilateral uterine artery notch and 56 (86%) did not, compared with 51 (24%) and 161 (76%), in the control group, respectively. Patients with first trimester vaginal bleeding, and a bilateral uterine artery notch had significantly higher rates of small for gestational age neonates, low-Apgar scores (<7) at one minute and cesarean deliveries compared to patients with first trimester vaginal bleeding who did not have bilateral uterine artery notch.

CONCLUSION

First trimester vaginal bleeding was not associated with a higher incidence of abnormal uterine artery waveforms or with placental related conditions. However, adverse perinatal outcomes were found when first trimester vaginal bleeding was associated with second and third trimester bilateral uterine artery notchs.

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.

Ultrasound Evaluation of Pregnancy in the First Trimester

Improvements in ultrasound technology, including transvaginal sonography and higher frequency probes, have led to a better understanding of early pregnancy development. These advances and the increasing availability of ultrasound allow women to have an earlier and more accurate assessment of their pregnancy. First trimester sonographic signs have been identified that can be used to reassure women that their pregnancy is progressing normally or counsel them that their pregnancy will fail. In addition, first trimester ultrasound can accurately predict the type of twinning in multiple gestations, allowing for appropriate counseling and management.

Objectives

Know the first trimester ultrasound findings of a normal intrauterine pregnancy

Understand the ultrasound findings that diagnose an early pregnancy failure

Know the ultrasound criteria used to diagnose a multifetal gestation

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.

Obstetric Outcome in Women With Threatened Miscarriage in the First Trimester

OBJECTIVE

To assess pregnancy outcomes in women with threatened miscarriage in the first trimester.

METHODS

This was a retrospective cohort study based on data extracted from the Aberdeen Maternity and Neonatal Databank. Cases included all primigravid women with first-trimester vaginal bleeding who delivered after 24 weeks of gestation between 1976 and 2004. The control group comprised all other women who had first pregnancies during the same period. Data were analyzed by univariate and multivariate statistical methods.

RESULTS

Compared with the control group (n = 31,633), women with threatened miscarriage (n = 7,627) were more likely to have antepartum hemorrhage of unknown origin (odds ratio [OR] 1.83, 95% confidence interval [CI] 1.73-2.01). Elective cesarean (OR 1.30, 95% CI 1.14-1.48) and manual removal of placenta (OR 1.40, 95% CI 1.21-1.62) were performed more frequently in these women, who also had a higher risk of preterm delivery (OR 1.56, 95% CI 1.43-1.71) and malpresentation (OR 1.26, 95% CI 1.13-1.40). Threatened miscarriage in the first trimester is required in 112, 112, 17, 85, 32 patients, respectively, for each additional case of manual removal of placenta, elective cesarean, antepartum hemorrhage of unknown origin, malpresentation, and preterm delivery.

CONCLUSION

Pregnancies complicated by threatened miscarriage are at a slightly higher risk of obstetric complications and interventions.

LEVEL OF EVIDENCE

II-2.

Risk factors for spontaneous abortion in early symptomatic first-trimester pregnancies

OBJECTIVE

To evaluate the association of an ultimate diagnosis of miscarriage with various clinical symptoms and historical factors in a cohort of women presenting with pain, bleeding, or both in the first trimester of pregnancy.

METHODS

This was a case-control study from a population of women presenting for care with pelvic pain or vaginal bleeding in the first trimester of pregnancy whose diagnoses were not definite upon initial evaluation. Analyses were performed in 2 ways. In one instance cases were defined as women ultimately definitively diagnosed with a miscarriage and controls were defined as women with a pregnancy that did not result in miscarriage (ectopic pregnancy or ongoing intrauterine pregnancy). The second analysis compared women with a miscarriage only to women who had an ongoing intrauterine pregnancy.

RESULTS

A total of 2,026 women were evaluated, with 1,192 ultimately diagnosed with a spontaneous abortion, 367 with ectopic pregnancy, and 467 with a viable intrauterine pregnancy. Although many risk factors were individually associated with miscarriage in preliminary analysis, in the final analysis only extremes in age (< 25 and > 35) and the complaint of bleeding (odds ratio [OR] 7.35, 95% confidence interval[CI] 5.74-9.41) were associated with miscarriage. The complaint of pain (OR 0.72, 95% CI 0.57-0.92), human chorionic gonadotropin (hCG) value greater than 500 (hCG < or = 500 IU/mL compared with hCG 501-2000: OR 0.52, 95% CI 0.39-0.69) and concurrent cervical infection (OR 0.69, 95% CI 0.55-0.88) were negatively associated with miscarriage.

CONCLUSION

Few factors predict miscarriage in women who present with a symptomatic first trimester pregnancy of unknown location. Heavy bleeding was most strongly associated with miscarriage. Concurrent cervical infections should not be overlooked as a cause of bleeding in early pregnancy and were not associated with miscarriage.

LEVEL OF EVIDENCE

II-2.

Dydrogesterone in threatened abortion: pregnancy outcome

OBJECTIVE

To determine whether therapy with dydrogesterone in threatened abortion during the first trimester of pregnancy will improve pregnancy outcome.

DESIGN

Prospective open study.

SUBJECTS

Pregnant women presenting to the obstetric and gynaecology clinic admitting center with vaginal bleeding before 13 weeks gestation were evaluated for entry into the study. Women were excluded if they had a history of recurrent miscarriage.

METHOD

Eligible subjects were randomized to receive either dydrogesterone 40 mg stat dose followed by 10 mg twice a day for one week or conservative therapy.

RESULTS

One hundred and 54 women were recruited. There was no statistically significant differences between the two groups with regard to pre-treatment status. The continuing pregnancy success rate was significantly (p=0.037) higher in women treated with dydrogesterone (95.9%) compared with women who received conservative treatment (86.3%). The odds ratio of the success rate between dydrogesterone treatment and non-treatment was 3.773 (95% confidence interval: 1.009-14.108).

CONCLUSION

Corpus luteal support with dydrogesterone has been shown to reduce the incidence of pregnancy loss in threatened abortion during the first trimester in women without a history of recurrent abortion.

Menstrual disorders in the college age female

College-age young women frequently experience a variety of menstrual-related complaints, including dysmenorrheal, menorrhagia, irregular menses, and menstrual-related mood changes. These problems deserve careful evaluation; they may reflect normal ovulatory menstrual symptoms or be suggestive of significant pathology that can have a major impact on future reproductive and general health. The menstrual cycle is a vital sign whose normalcy suggests an overall good health and whose abnormality requires evaluation. Eating disorders and the female athlete triad increase the risk of osteoporosis; polycystic ovary syndrome is associated with future cardiovascular risks. Diagnosis and management of these problems will not only improve a young woman's current health, sense of well-being, and overall quality of life but may also lower her risks for future disease and ill-health. This article addresses normal menstrual function, excessive bleeding, infrequent or absent menses, pain with menses, menstrual-related mood disorders, and recommendations about routine gynecologic examinations and evaluation.

Threatened abortion: A risk factor for poor pregnancy outcome, a population-based screening study

OBJECTIVE

The purpose of this study was to determine whether patients with first-trimester threatened abortion are at increased risk for poor pregnancy outcome.

STUDY DESIGN

A large prospective multicenter database was studied. Subjects were divided into three groups: (1) no bleeding, (2) light bleeding, and (3) heavy bleeding. Univariate and multivariable logistic regression analyses were used.

RESULTS

The study comprised 16,506 patients: 14,160 patients without bleeding, 2094 patients with light bleeding, and 252 patients with heavy bleeding. Patients with vaginal bleeding, light or heavy, were more likely to experience a spontaneous loss before 24 weeks of gestation (odds ratio, 2.5 and 4.2, respectively) and cesarean delivery (odds ratio, 1.1 and 1.4, respectively). Light bleeding subjects were more likely to have preeclampsia (odds ratio, 1.5), preterm delivery (odds ratio, 1.3), and placental abruption (odds ratio, 1.6). Heavy vaginal bleeding subjects were more likely to have intrauterine growth restriction (odds ratio, 2.6), preterm delivery (odds ratio, 3.0), preterm premature rupture of membranes (odds ratio, 3.2), and placental abruption (odds ratio, 3.6).

CONCLUSION

First-trimester vaginal bleeding is an independent risk factor for adverse obstetric outcome that is directly proportional to the amount of bleeding.

T-helper 2-cytokine levels in women with threatened abortion

OBJECTIVE

Considering that successful embryo development has been immunologically attributed to a T-helper 2 phenomenon and that threatened abortion is a very frequent but pathogenetically not well-defined clinical entity, our purpose was to investigate serum levels of the main T-helper 2-type cytokines during the evolution of this condition.

STUDY DESIGN

Three T-helper 2-type cytokines (interleukin-6 (IL-6), interleukin-10 (IL-10), interleukin-13 (IL-13)) were measured by an enzyme-linked immunosorbent assay (ELISA) in serum of 12 women with threatened abortion both at hospital admission and discharge time. Fourteen women with missed abortion, 14 normal pregnant women and 14 normal non-pregnant women represent study control groups.

RESULTS

Serum concentrations of the selected T-helper 2-type cytokines showed no significant differences in women with threatened abortion with those of normal pregnant and non-pregnant women, whereas showed significantly lower values in women with missed abortion.

CONCLUSION

Our data (a) confirm the concept that first-trimester normal pregnancy is a T-helper 2 phenomenon, (b) show that threatened abortion, when T-helper 2-biased, may tend to a positive evolution of the condition, (c) display that interleukin-10, particularly, may represent a useful diagnostic and prognostic marker for predicting the normal continuance of the pregnancy in threatened abortion, (d) confirm the existence of a T-helper 2-type pattern deficiency in missed abortion, and finally (e) may open the way to new T-helper 2-biased immune therapies in case of difficult first-trimester pregnancies.