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Al-Memar M, Fourie H, Vaulet T, Lawson K, Bobdiwala S, Saso S, Farren J, Pipi M, De Moor B, Stalder C, Bennett P, Timmerman D, Bourne T. Using simple clinical and ultrasound variables to develop a model to predict first trimester pregnancy viability. Eur J Obstet Gynecol Reprod Biol 2024; 292:187-193. [PMID: 38039901 DOI: 10.1016/j.ejogrb.2023.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 11/16/2023] [Accepted: 11/21/2023] [Indexed: 12/03/2023]
Abstract
INTRODUCTION Early prediction of pregnancies destined to miscarry will allow couples to prepare for this common but often unexpected eventuality, and clinicians to allocate finite resources. We aimed to develop a prediction model combining clinical, demographic, and sonographic data as a clinical tool to aid counselling about first trimester pregnancy outcome. MATERIAL AND METHODS This is a prospective, observational cohort study conducted at Queen Charlotte's and Chelsea Hospital, UK from March 2014 to May 2019. Women with confirmed intrauterine pregnancies between 5 weeks and their dating scan (11-14 weeks) were recruited. Participants attended serial ultrasound scans in the first trimester and at each visit recorded symptoms of vaginal bleeding, pelvic pain, nausea and vomiting using validated scoring tools. Pregnancies were followed up until the dating scan (11-14 weeks). Univariate and multivariate analyses were performed to predict first trimester viability. A model was developed with multivariable logistic regression, variables limited by feature selection, and bootstrapping with multiple imputation was used for internal validation. RESULTS 1403 women were recruited and after exclusions, data were available for 1105. 160 women (14.5 %) experienced first trimester miscarriage and 945 women (85.5 %) had viable pregnancies at 11-14 weeks' gestation. The average gestational age at the initial visit (calculated from the menstrual dates) was 7 + 1 weeks (+/-12.2 days). A multivariable logistic regression model was developed to predict first trimester viability and included the variables: mean gestational sac diameter, presence of fetal heart pulsations, difference in gestational age from last menstrual period and from mean sac diameter on ultrasonography, current folic acid usage and maternal age. The model demonstrated good performance (optimism-corrected area under curve (AUC) 0.84, 95 % CI 0.81-0.87; optimism-corrected calibration slope 0.969). CONCLUSION We have developed and internally validated a model to predict first trimester viability with good accuracy prior to the 11-14 week dating scan, which now needs to be externally validated prior to clinical use.
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Affiliation(s)
- Maya Al-Memar
- Tommy's National Early Miscarriage Research Centre, Queen Charlotte's & Chelsea Hospital, Imperial College, Du Cane Road, London W12 0HS, UK
| | - Hanine Fourie
- Tommy's National Early Miscarriage Research Centre, Queen Charlotte's & Chelsea Hospital, Imperial College, Du Cane Road, London W12 0HS, UK
| | - Thibaut Vaulet
- ESAT-STADIUS, Stadius Centre for Dynamical Systems, Signal Processing and Data Analytics, Kasteelpark Arenberg 10 -box2446, 3001 Leuven, Belgium
| | - Kim Lawson
- Queen Charlotte's and Chelsea Hospital, Imperial College, London, UK
| | - Shabnam Bobdiwala
- Tommy's National Early Miscarriage Research Centre, Queen Charlotte's & Chelsea Hospital, Imperial College, Du Cane Road, London W12 0HS, UK
| | - Srdjan Saso
- Tommy's National Early Miscarriage Research Centre, Queen Charlotte's & Chelsea Hospital, Imperial College, Du Cane Road, London W12 0HS, UK
| | - Jessica Farren
- Tommy's National Early Miscarriage Research Centre, Queen Charlotte's & Chelsea Hospital, Imperial College, Du Cane Road, London W12 0HS, UK
| | - Maria Pipi
- Tommy's National Early Miscarriage Research Centre, Queen Charlotte's & Chelsea Hospital, Imperial College, Du Cane Road, London W12 0HS, UK
| | - Bart De Moor
- ESAT-STADIUS, Stadius Centre for Dynamical Systems, Signal Processing and Data Analytics, Kasteelpark Arenberg 10 -box2446, 3001 Leuven, Belgium
| | - Catriona Stalder
- Tommy's National Early Miscarriage Research Centre, Queen Charlotte's & Chelsea Hospital, Imperial College, Du Cane Road, London W12 0HS, UK
| | - Phillip Bennett
- Tommy's National Early Miscarriage Research Centre, Queen Charlotte's & Chelsea Hospital, Imperial College, Du Cane Road, London W12 0HS, UK
| | - Dirk Timmerman
- Queen Charlotte's and Chelsea Hospital, Imperial College, London, UK; KU Leuven, Department of Development and Regeneration, Leuven, Belgium
| | - Tom Bourne
- Tommy's National Early Miscarriage Research Centre, Queen Charlotte's & Chelsea Hospital, Imperial College, Du Cane Road, London W12 0HS, UK; Queen Charlotte's and Chelsea Hospital, Imperial College, London, UK; KU Leuven, Department of Development and Regeneration, Leuven, Belgium; Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium.
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Park KE, Latack KR, Vestal NL, Ingles SA, Paulson RJ, Awadalla MS. Association of HCG Level with Ultrasound Visualization of the Gestational Sac in Early Viable Pregnancies. Reprod Sci 2023; 30:3623-3628. [PMID: 37563479 PMCID: PMC10692031 DOI: 10.1007/s43032-023-01308-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/10/2023] [Indexed: 08/12/2023]
Abstract
Our primary objective is to verify or refute a 2013 study by Connolly et al. which showed that in early pregnancy, a gestational sac was visualized 99% of the time on transvaginal ultrasound when the HCG level reached 3510 mIU/mL. Our secondary objective was to make clinical correlations by assessing the relationship between human chorionic gonadotropin (HCG) level in early pregnancy when a gestational sac is not seen and pregnancy outcomes of live birth, spontaneous abortion, and ectopic pregnancy. This retrospective study includes 144 pregnancies with an outcome of live birth, 87 pregnancies with an outcome of spontaneous abortion, and 59 ectopic pregnancies. Logistic regression is used to determine the probability of visualizing a gestational sac and/or yolk sac based on the HCG level. A gestational sac is predicted to be visualized 50% of the time at an HCG level of 979 mIU/mL, 90% at 2421 mIU/mL, and 99% of the time at 3994 mIU/mL. A yolk sac was predicted to be visualized 50% of the time at an HCG level of 4626 mIU/mL, 90% at 12,892 mIU/mL, and 99% at 39,454 mIU/mL. A total of 90% of ectopic pregnancies presented with an HCG level below 3994 mIU/mL. These results are in agreement with the study by Connolly et al. Since most early ectopic pregnancies had an HCG value below the discriminatory level for gestational sac visualization, other methods for the evaluation of pregnancy of unknown location such as repeat HCG values are clinically important.
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Affiliation(s)
- Kristen E Park
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Kyle R Latack
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Nicole L Vestal
- Department of Pediatrics, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Sue A Ingles
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Richard J Paulson
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Michael S Awadalla
- Institute for Reproductive Health, 3805 Edwards Rd Suite 450, Cincinnati, OH, 45209, USA.
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White R, Kilgour Venables H. The significance of ultrasound features of sub-chorionic haemorrhage as a predictor of adverse perinatal outcome: A retrospective review. Eur J Obstet Gynecol Reprod Biol 2023; 289:23-28. [PMID: 37619520 DOI: 10.1016/j.ejogrb.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION This retrospective single centre study considers the predictive value of specific ultrasound features of sub-chorionic haemorrhage (SCH) as potential indicators of adverse pregnancy outcome. METHODS Ultrasound reports and images were reviewed for 160 participants presenting to an early pregnancy assessment unit from January 2018 to January 2019. Participants were selected based upon the presence of SCH within the first trimester. The outcome of each pregnancy and the features of SCH, including the size, location and echogenicity were recorded and multinominal logistic regression was used to establish predictive value. RESULTS The majority of participants were asymptomatic and delivered healthy babies. 24% miscarried prior to delivery or had stillborn babies; the features of bleed within this group revealed an increased prevalence of adverse outcome in the presence of moderate sized haemorrhage (p = 0.02). 61% of miscarried pregnancies presented with "wrapping" SCH, in which haemorrhage encased the gestation sac, suggesting wrapping posed a probable risk (p = 0.01). 71% of miscarriages occurred within 5 + 0-10 + 0 weeks gestation. Persistent SCH was of greater incidence within those participants with adverse outcome (57%). There was no association between fetal abnormality and miscarriage. Jaundice babies and premature delivery occurred more frequently (p = 0.001) and may be a secondary finding following SCH. CONCLUSION There was a strong correlation between presence of SCH in early pregnancy and rate of miscarriage. Specific ultrasound features of SCH, most notably a wrapping location with moderate size, may be indicative of increased risk of miscarriage or post-natal complications. Jaundice and premature births may have an association with placental compromise.
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Simcock IC, Lamouroux A, Sebire NJ, Shelmerdine SC, Arthurs OJ. Less-invasive autopsy for early pregnancy loss. Prenat Diagn 2023; 43:937-949. [PMID: 37127547 DOI: 10.1002/pd.6361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/03/2023]
Abstract
Autopsy investigations provide valuable information regarding fetal death that can assist in the parental bereavement process, and influence future pregnancies, but conventional autopsy is often declined by parents because of its invasive approach. This has led to the development of less-invasive autopsy investigations based on imaging technology to provide a more accessible and acceptable choice for parents when investigating their loss. Whilst the development and use of more conventional clinical imaging techniques (radiographs, CT, MRI, US) are well described in the literature for fetuses over 20 weeks of gestational age, these investigations have limited diagnostic accuracy in imaging smaller fetuses. Techniques such as ultra-high-field MRI (>3T) and micro-focus computed tomography have been shown to have higher diagnostic accuracy whilst still being acceptable to parents. By further developing and increasing the availability of these more innovative imaging techniques, parents will be provided with a greater choice of acceptable options to investigate their loss, which may in turn increase their uptake. We provide a narrative review focussing on the development of high-resolution, non-invasive imaging techniques to evaluate early gestational pregnancy loss.
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Affiliation(s)
- Ian C Simcock
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, UK
- UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Audrey Lamouroux
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, UK
- Obstetrical Gynaecology Department, Nîmes University Hospital, Nîmes, France
- Clinical Genetics Department, Montpellier University Hospital, Montpellier, France
- ICAR Research Team, LIRMM, CNRS and Charles Coulomb Laboratory, UMR 5221 CNRS-UM, BNIF User Facility Imaging, University of Montpellier, Nîmes and Montpellier, Montpellier, France
| | - Neil J Sebire
- UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
- Department of Histopathology, Great Ormond Street Hospital for Children, London, UK
| | - Susan C Shelmerdine
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, UK
- UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Owen J Arthurs
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, UK
- UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
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Duncan CI, Reynolds-Wright JJ, Cameron ST. Utility of a routine ultrasound for detection of ectopic pregnancies among women requesting abortion: a retrospective review. BMJ Sex Reprod Health 2022; 48:22-27. [PMID: 33376099 PMCID: PMC8762027 DOI: 10.1136/bmjsrh-2020-200888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/05/2020] [Accepted: 12/07/2020] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Routine ultrasound may be used in abortion services to determine gestational age and confirm an intrauterine pregnancy. However, ultrasound adds complexity to care and results may be inconclusive, delaying abortion. We sought to determine the rate of ectopic pregnancy and the utility of routine ultrasound in its detection, in a community abortion service. METHODS Retrospective case record review of women requesting abortion over a 5-year period (2015-2019) with an outcome of ectopic pregnancy or pregnancy of unknown location (PUL) at a service (Edinburgh, UK) conducting routine ultrasound on all women. Records were searched for symptoms at presentation, development of symptoms during clinical care, significant risk factors and routine ultrasound findings. RESULTS Only 29/11 381 women (0.25%, 95% CI 0.18%, 0.33%) had an ectopic pregnancy or PUL (tubal=18, caesarean scar=1, heterotopic=1, PUL=9). Eleven (38%) cases had either symptoms at presentation (n=8) and/or significant risk factors for ectopic pregnancy (n=4). A further 12 women developed symptoms during their clinical care. Of the remaining six, three were PUL treated with methotrexate and three were ectopic (salpingectomy=2, methotrexate=1). In three cases, the baseline ultrasound indicated a probable early intrauterine pregnancy. CONCLUSIONS Ectopic pregnancies are uncommon among women presenting for abortion. The value of routine ultrasound in excluding ectopic pregnancy in symptom-free women without significant risk factors is questionable as it may aid detection of some cases but may provide false reassurance that a pregnancy is intrauterine.
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Affiliation(s)
- Clara I Duncan
- The Medical School, University of Edinburgh, Edinburgh, UK
| | - John J Reynolds-Wright
- Queen's Medical Research Institute, MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
- NHS Lothian, Chalmers Centre, Edinburgh, UK
| | - Sharon T Cameron
- Queen's Medical Research Institute, MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
- NHS Lothian, Chalmers Centre, Edinburgh, UK
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Lisova KM, Kalinovska I, Tokar P. ULTRASOUND CHARACTERISTIC OF EMBRYO, FETAL EGG AND CHORIONIC STRUCTURES IN PREGNANT WOMEN WITH MISCARRIAGE. Wiad Lek 2022; 75:75-78. [PMID: 35092251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE The aim: The aim of the study was to assess the peculiarities of the formation and development of the fetoplacental system, to study the structures of the embryo, gestational sac, chorion in pregnant women with miscarriage. PATIENTS AND METHODS Materials and methods: A comprehensive ultrasound examination of 50 pregnant women was carried out in the period from 5 to 16 weeks of pregnancy, of which 25 - with a history of miscarriage (main group), and 25 - with an unremarkable medical history (control group). RESULTS Results: We have identified the following echographic markers of adverse course and outcome of pregnancy in women with miscarriage in embryonic and early fetal periods:- lag of CRL of an embryo by 2 weeks and more at ultrasound examination in terms up to 9 weeks of gestation;- corporal or basal (near the stem of the embryo body) location of chorionic detachment with the formation of retrochorial hematoma with a volume of more than 25 ml;- pronounced progressive decrease in the volume of the gestational sac and amniotic cavity;- pronounced polyhydramnios with the presence of a coarse echopositive suspension in the amnioticcavity. The likelihood of spontaneous miscarriage and the formation of placental dysfunction is higher with the simultaneous detection of 2 or more echographic markers. CONCLUSION Conclusions: Ultrasound examination is necessary to assess the echographic parameters of the formation and development of the embryo and extraembryonic structures in the first trimester with a history of miscarriage in order to the subsequent choice of rational tactics of pregnancy management.
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Affiliation(s)
| | | | - Petro Tokar
- BUKOVINIAN STATE MEDICAL UNIVERSITY, CHERNIVTSI, UKRAINE
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Abbara A, Al-Memar M, Phylactou M, Kyriacou C, Eng PC, Nadir R, Izzi-Engbeaya C, Clarke SA, Mills EG, Daniels E, Huo L, Pacuszka E, Yang L, Patel B, Tan T, Bech P, Comninos AN, Fourie H, Kelsey TW, Bourne T, Dhillo WS. Performance of plasma kisspeptin as a biomarker for miscarriage improves with gestational age during the first trimester. Fertil Steril 2021; 116:809-819. [PMID: 34053677 PMCID: PMC8445632 DOI: 10.1016/j.fertnstert.2021.04.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 04/17/2021] [Accepted: 04/20/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To compare the performance of kisspeptin and beta human chorionic gonadotropin (βhCG), both alone and in combination, as biomarkers for miscarriage throughout the first trimester. DESIGN Prospective, nested case-control study. SETTING Tertiary Centre, Queen Charlotte Hospital, London, United Kingdom. PATIENT(S) Adult women who had miscarriages (n = 95, 173 samples) and women with healthy pregnancies (n = 265, 557 samples). INTERVENTION(S) The participants underwent serial ultrasound scans and blood sampling for measurement of plasma kisspeptin and βhCG levels during the first trimester. MAIN OUTCOME MEASURE(S) The ability of plasma kisspeptin and βhCG levels to distinguish pregnancies complicated by miscarriage from healthy pregnancies unaffected by miscarriage. RESULT(S) Gestation-adjusted levels of circulating kisspeptin and βhCG were lower in samples from women with miscarriages than in women with healthy pregnancies by 79% and 70%, respectively. The area under the receiver-operating characteristic curve for identifying miscarriage during the first trimester was 0.874 (95% confidence interval [CI] 0.844-0.904) for kisspeptin, 0.859 (95% CI 0.820-0.899) for βhCG, and 0.916 (95% CI 0.886-0.946) for the sum of the two markers. The performance of kisspeptin in identifying miscarriage improved with increasing length of gestation, whereas that of βhCG worsened. A decision matrix incorporating kisspeptin, βhCG, and gestational age had 83% to 87% accuracy for the prediction of miscarriage. CONCLUSION(S) Plasma kisspeptin is a promising biomarker for miscarriage and provides additional value to βhCG alone, especially during later gestational weeks of the first trimester.
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Affiliation(s)
- Ali Abbara
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Maya Al-Memar
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, United Kingdom
| | - Maria Phylactou
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Christopher Kyriacou
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, United Kingdom
| | - Pei Chia Eng
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Rans Nadir
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Chioma Izzi-Engbeaya
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Sophie A Clarke
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Edouard G Mills
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Elisabeth Daniels
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Lechun Huo
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Ewa Pacuszka
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Lisa Yang
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Bijal Patel
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Tricia Tan
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Paul Bech
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Alexander N Comninos
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Hanine Fourie
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, United Kingdom
| | - Tom W Kelsey
- School of Computer Science, University of St. Andrews, St. Andrews, United Kingdom
| | - Tom Bourne
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, United Kingdom; Katholieke Universiteit Leuven, Department of Development and Regeneration, Leuven, Belgium
| | - Waljit S Dhillo
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom.
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Karavani G, Alexandroni H, Sheinin D, Dior UP, Simon A, Ben-Meir A, Reubinoff B. Endometrial thickness following early miscarriage in IVF patients - is there a preferred management approach? Reprod Biol Endocrinol 2021; 19:93. [PMID: 34158067 PMCID: PMC8218428 DOI: 10.1186/s12958-021-00780-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/10/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Endometrial thickness (ET) has previously been shown to positively correlate with implantation and clinical pregnancy rates. Pregnancies achieved using in-vitro fertilization (IVF) technique are prone to higher rates of early miscarriage. The aim of this study was to compare the effects of expectant management, medical treatment (Misoprostol) and dilation and curettage (D&C) for early miscarriage following IVF cycles on the subsequent cycle outcomes - endometrial thickness and reproductive outcomes. METHODS A retrospective cohort study of women who underwent embryo transfer, conceived and had first trimester miscarriage with at least one subsequent embryo transfer. ET measurements during fresh or frozen-thawed IVF cycles were assessed for each patient. Comparisons of ET differences between the miscarriage and the subsequent cycles, as well as reproductive outcomes, were performed according to the initial miscarriage management approach. RESULTS A total of 223 women were included in the study. Seventy-eight women were managed conservatively, 61 were treated with Misoprostol and 84 women underwent D&C. Management by D&C, compared to conservative management and Misoprostol treatment was associated with higher prevalence of a significant (> 2 mm) ET decrease (29.8%% vs. 14.1and 6.6%, respectively; p < .001) and was the only approach associated with a significant increase in the rates of ET under 7 and 8 mm in the following cycle (p = 0.006 and 0.035; respectively). Clinical pregnancy rates were significantly lower following D&C compared with conservative management and Misoprostol (16.7% vs. 38.5 and 27.9%, respectively; p = 0.008) as well as implantation rate (11.1% vs. 30.5.% and 17.7, respectively; p < 0.001). CONCLUSION Our data suggest that D&C management of a miscarriage is associated with decreased ET and higher rates of thin endometrium in the subsequent IVF cycle, compared with conservative management and Misoprostol treatment. In addition, implantation and pregnancy rates were significantly lower after D&C.
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Affiliation(s)
- Gilad Karavani
- Infertility and IVF Unit, Department of Obstetrics and Gynecology, Hadassah Ein-Kerem Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Heli Alexandroni
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Daniel Sheinin
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Uri P Dior
- Infertility and IVF Unit, Department of Obstetrics and Gynecology, Hadassah Ein-Kerem Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Alex Simon
- Infertility and IVF Unit, Department of Obstetrics and Gynecology, Hadassah Ein-Kerem Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Assaf Ben-Meir
- Infertility and IVF Unit, Department of Obstetrics and Gynecology, Hadassah Ein-Kerem Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Benjamin Reubinoff
- Infertility and IVF Unit, Department of Obstetrics and Gynecology, Hadassah Ein-Kerem Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
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Barnhart KT, Senapati S, Sammel MD. Declaring a gestation nonviable: when 99% certainty is not enough. Am J Obstet Gynecol 2021; 224:232-233. [PMID: 33065133 DOI: 10.1016/j.ajog.2020.10.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/21/2020] [Accepted: 10/09/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Kurt T Barnhart
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Pennsylvania Medical Center, 3701 Market St., Ste. 800, Philadelphia, PA 19104.
| | - Suneeta Senapati
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Pennsylvania Medical Center, 3701 Market St., Ste. 800, Philadelphia, PA 19104
| | - Mary D Sammel
- Department of Biostatics and Informatics, Colorado School of Public Health & University of Colorado School of Medicine, Aurora, CO
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Shaamash AH, Aly HA, Abdel-Aleem M, Akhnowkh SN. Clinical and Ultrasound Evaluation of Early Threatened Miscarriage to Predict Pregnancy Continuation up to 28 Weeks: A Prospective Cohort Study. J Ultrasound Med 2020; 39:1777-1785. [PMID: 32314402 DOI: 10.1002/jum.15282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 03/09/2020] [Accepted: 03/12/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES (1) To study the predictors of pregnancy continuation up to 28 weeks in first-trimester threatened miscarriage after a single clinical and ultrasound (US) evaluation. (2) To assess the role of both clinical and US predictors in counseling and decreasing repeated emergency follow-up scans. METHODS A prospective observational study that included a cohort of 241 patients with threatened miscarriage (≥6-12 weeks) was conducted. They had a single clinical and US evaluation, and then they were contacted by weekly phone calls until completing 28 weeks' gestation or reporting miscarriage. Independently, all patients were followed by the recommended routine US scanning with or without emergency visits. RESULTS Two hundred thirty-three patients completed the study, of whom 193 patients continued up to 28 weeks' gestation, and 40 miscarried (17.1%). Only spotting/mild bleeding episodes and progesterone treatment were the clinical predictors of fetal viability. The embryonic/fetal heart rate (E/FHR) was the best single US predictor, with a specificity and positive predictive value of 95.3% and 97.2%, respectively. Combining 3 US parameters, at their best cutoff points (E/FHR >113 beats per minute, crown-rump length >19.9 mm, and gestational sac diameter >27.3 mm), had a specificity and positive predictive value of 98% and 99% (first-trimester US triad of fetal viability). CONCLUSIONS [1] In first-trimester threatened miscarriage, clinical parameters that could predict fetal viability included spotting/ mild bleeding and progesterone treatment. [2] After a single US scan, the presence of at least an E/FHR of greater than 113 bpm or the suggested first-trimester US triad appeared as a simple, measurable, and effective predictor of pregnancy continuation up to 28 weeks. [3] These US predictors are not to replace the recommended scheduled scanning during pregnancy. [4] This can improve patients' counseling and decrease the need for repeated emergency follow-up scans. Otherwise, there is an indication for repeating US scans at a 1-week to 10-day interval.
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Affiliation(s)
- Ayman H Shaamash
- Department of Obstetrics and Gynecology, Woman's Health Hospital, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Hany A Aly
- Department of Obstetrics and Gynecology, Woman's Health Hospital, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mahmoud Abdel-Aleem
- Department of Obstetrics and Gynecology, Woman's Health Hospital, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Seham N Akhnowkh
- Department of Obstetrics and Gynecology, El-eman Hospital, Ministry of Health, Assiut, Egypt
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Gomes DJ, Kaufman B, Aluisio AR, Kendall S, Thomas V, Bloem C. Assessment of Acute Obstetrical Needs and the Potential Utility of Point-Of-Care Ultrasound in the North East Region of Haiti: A Cross-Sectional Study. Ann Glob Health 2020; 86:72. [PMID: 32676301 PMCID: PMC7333557 DOI: 10.5334/aogh.2597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Point-of-care ultrasound (POCUS) implemented through task shifting to nontraditional users has potential as a diagnostic adjuvant to enhance acute obstetrical care in resource-constrained environments with limited access to physician providers. Objective This study evaluated acute obstetrical needs and the potential role for POCUS programming in the North East region of Haiti. Methods Data was collected on all women presenting to the obstetrical departments of two Ministry of Public Health and Population (MSPP)-affiliated public hospitals in the North East region of Haiti: Fort Liberté Hospital and Centre Medicosocial de Ouanaminthe. Data was obtained via retrospective review of hospital records from January 1 through March 31, 2016. Trained personnel gathered data on demographics, obstetrical history, diagnoses, clinical care and outcomes using a standardized tool. Diagnoses a priori, defined as those diagnoses whose detection could be assisted with POCUS, included multi-gestations, non-vertex presentation, cephalopelvic disproportion, placental abruption, placenta previa, spontaneous abortions, retained products and ectopic pregnancy. Results Data were collected from 589 patients during the study period. Median maternal age was 26 years and median gestational age was 38 weeks. The most common reason for seeking care was pelvic pain (85.2%). Sixty-seven (11.5%) women were transferred to other facilities for higher-level care. Among cases not transferred, post-partum hemorrhage, infant mortality and maternal mortality occurred in 2.4%, 3.0% and 0.6% of cases, respectively. There were 69 cases with diagnoses that could have benefited from POCUS use. Between sites, significantly more cases had the potential for improved diagnostics with POCUS at Fort Liberté Hospital (19.8%) than Centre Medicosocial de Ouanaminthe (8.2%) (p < 0.001). Conclusion Acute obstetrical care is common and POCUS has the potential to impact the care of obstetrical patients in the North East region of Haiti. Future programs evaluating the feasibility of task shifting and the sustainable impacts of acute obstetric POCUS in Haiti will be important.
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Affiliation(s)
- Danica J. Gomes
- Department of Emergency Medicine, Division of International Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, NY, US
| | - Benjamin Kaufman
- Department of Emergency Medicine, Division of Global Emergency Medicine, Columbia University, New York, NY, US
| | - Adam R. Aluisio
- Department of Emergency Medicine, Division of International Emergency Medicine, Alpert Medical School of Brown University, Providence, RI, US
| | - Scott Kendall
- Department of Emergency Medicine, Division of International Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, NY, US
| | - Vladimir Thomas
- Department of Emergency Medicine, Division of International Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, NY, US
| | - Christina Bloem
- Department of Emergency Medicine, Division of International Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, NY, US
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12
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Bourne T, Kyriacou C, Coomarasamy A, Al‐Memar M, Leonardi M, Kirk E, Landolfo C, Blanchette‐Porter M, Small R, Condous G, Timmerman D. ISUOG Consensus Statement on rationalization of early-pregnancy care and provision of ultrasonography in context of SARS-CoV-2. Ultrasound Obstet Gynecol 2020; 55:871-878. [PMID: 32267981 PMCID: PMC7262213 DOI: 10.1002/uog.22046] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Affiliation(s)
- T. Bourne
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial CollegeLondonUK
- Department of Obstetrics and GynaecologyUniversity Hospitals LeuvenLeuvenBelgium
- KU LeuvenDepartment of Development and RegenerationLeuvenBelgium
| | - C. Kyriacou
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial CollegeLondonUK
| | - A. Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of BirminghamBirminghamUK
| | - M. Al‐Memar
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial CollegeLondonUK
| | - M. Leonardi
- Acute Gynecology, Early Pregnancy & Advanced Endoscopic Surgery Unit, Sydney Medical School Nepean, University of Sydney Nepean HospitalPenrith, SydneyAustralia
| | - E. Kirk
- Early Pregnancy and Acute Gynaecology Unit, Royal Free NHS Foundation TrustLondonUK
| | - C. Landolfo
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità PubblicaRomeItaly
| | - M. Blanchette‐Porter
- Larner College of Medicine at University of Vermont ObstetricsGynecology, and Reproductive Sciences Division, Reproductive Medicine and Infertility BurlingtonVermontUSA
| | - R. Small
- Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation TrustBordesley Green East, BirminghamUK
| | - G. Condous
- Acute Gynecology, Early Pregnancy & Advanced Endoscopic Surgery Unit, Sydney Medical School Nepean, University of Sydney Nepean HospitalPenrith, SydneyAustralia
| | - D. Timmerman
- Department of Obstetrics and GynaecologyUniversity Hospitals LeuvenLeuvenBelgium
- KU LeuvenDepartment of Development and RegenerationLeuvenBelgium
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13
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Grewal K, Al-Memar M, Fourie H, Stalder C, Timmerman D, Bourne T. Natural history of pregnancy-related enhanced myometrial vascularity following miscarriage. Ultrasound Obstet Gynecol 2020; 55:676-682. [PMID: 31503383 DOI: 10.1002/uog.21872] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/29/2019] [Accepted: 08/30/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Our primary aim was to report the incidence of enhanced myometrial vascularity (EMV) in consecutive women attending our early pregnancy assessment unit, following first-trimester miscarriage. We aimed further to evaluate the clinical presentation and complications associated with expectant and surgical management of EMV in these women. METHODS This was a prospective cohort study conducted in a London teaching hospital between June 2015 and June 2018, including consecutive patients with an observation of EMV on transvaginal ultrasonography following first-trimester miscarriage. The diagnosis was made following the subjective identification of EMV using color Doppler ultrasonography and a peak systolic velocity (PSV) ≥ 20 cm/s within the collection of vessels. Women were followed up with repeat scans every 14 days. Management was expectant unless intervention was indicated because of excessive or prolonged bleeding, persistent presence of retained tissue in the endometrial cavity or patient choice. The final clinical outcome was recorded. Time to resolution of EMV was defined as the interval from detection of EMV until resolution. RESULTS During the study period, there were 2627 first-trimester fetal losses in the department and, of these, 40 patients were diagnosed with EMV, hence the incidence of EMV following miscarriage was 1.52%. All cases were associated with ultrasound evidence of retained products of conception (RPOC) at presentation (mean dimensions, 22 × 20 × 20 mm). Thirty-one patients opted initially for expectant management, of which 18 had successful resolution without intervention, five were lost to follow-up and eight subsequently had surgical evacuation due to patient choice. No expectantly managed case required emergency intervention. Nine patients chose surgical evacuation as primary treatment. No significant correlation was seen between PSV within the EMV at presentation and blood loss at surgery. Median PSV was 47 (range, 20-148) cm/s. The estimated blood loss in all cases managed surgically ranged from 20-300 mL. Presence of RPOC was confirmed in all specimens that were sent for analysis following surgery. For cases successfully managed expectantly, the mean time to resolution was 48 (range, 21-84) days. In the nine cases managed surgically from the beginning, the mean time to resolution of EMV was 10.6 (range, 3-29) days. CONCLUSIONS This study suggests that EMV is an uncommon finding following miscarriage and is associated with the presence of RPOC. Expectant management was a safe option in our cohort, with minimal bleeding, although it was associated with protracted time to resolution. In patients who opted for surgery, the maximum blood loss was 300 mL and no patient required blood transfusion or embolization. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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MESH Headings
- Abortion, Spontaneous/diagnostic imaging
- Adult
- Female
- Humans
- Incidence
- London
- Myometrium/blood supply
- Myometrium/diagnostic imaging
- Neovascularization, Pathologic/diagnostic imaging
- Neovascularization, Pathologic/epidemiology
- Neovascularization, Pathologic/etiology
- Placenta, Retained/diagnostic imaging
- Placenta, Retained/etiology
- Pregnancy
- Pregnancy Trimester, First
- Prospective Studies
- Ultrasonography, Doppler, Color
- Ultrasonography, Prenatal
- Watchful Waiting
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Affiliation(s)
- K Grewal
- Tommy's National Centre for Miscarriage Research, Institute of Reproductive & Developmental Biology, Imperial College London, Hammersmith Hospital Campus, London, UK
| | - M Al-Memar
- Tommy's National Centre for Miscarriage Research, Institute of Reproductive & Developmental Biology, Imperial College London, Hammersmith Hospital Campus, London, UK
| | - H Fourie
- Tommy's National Centre for Miscarriage Research, Institute of Reproductive & Developmental Biology, Imperial College London, Hammersmith Hospital Campus, London, UK
| | - C Stalder
- Queen Charlotte's Hospital, Hammersmith Hospital Campus, Imperial College London, London, UK
| | - D Timmerman
- Department of Obstetrics and Gynecology, University Hospitals KU Leuven, Leuven, Belgium
| | - T Bourne
- Tommy's National Centre for Miscarriage Research, Institute of Reproductive & Developmental Biology, Imperial College London, Hammersmith Hospital Campus, London, UK
- Queen Charlotte's Hospital, Hammersmith Hospital Campus, Imperial College London, London, UK
- Department of Obstetrics and Gynecology, University Hospitals KU Leuven, Leuven, Belgium
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14
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Leong GTT, Leonardi M, Lu C, Mein B, Espada M, Shakeri B, Nadim B, Reid S, Casikar I, Condous G. Doppler Color Scoring System in Women With an Incomplete Miscarriage: Interobserver and Intraobserver Reproducibility Study. J Ultrasound Med 2019; 38:2437-2445. [PMID: 30693977 DOI: 10.1002/jum.14942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/10/2018] [Accepted: 12/21/2018] [Indexed: 06/09/2023]
Abstract
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.
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Affiliation(s)
- Grace Ting Ting Leong
- Acute Gynecology, Early Pregnancy & Advanced Endoscopic Surgery Unit, Sydney Medical School Nepean, University of Sydney Nepean Hospital, Penrith, Sydney, Australia
| | - Mathew Leonardi
- Acute Gynecology, Early Pregnancy & Advanced Endoscopic Surgery Unit, Sydney Medical School Nepean, University of Sydney Nepean Hospital, Penrith, Sydney, Australia
| | - Chuan Lu
- Department of Computer Sciences, Aberystwyth University, Wales, United Kingdom
| | - Brendan Mein
- Acute Gynecology, Early Pregnancy & Advanced Endoscopic Surgery Unit, Sydney Medical School Nepean, University of Sydney Nepean Hospital, Penrith, Sydney, Australia
| | - Mercedes Espada
- Acute Gynecology, Early Pregnancy & Advanced Endoscopic Surgery Unit, Sydney Medical School Nepean, University of Sydney Nepean Hospital, Penrith, Sydney, Australia
| | - Babak Shakeri
- Acute Gynecology, Early Pregnancy & Advanced Endoscopic Surgery Unit, Sydney Medical School Nepean, University of Sydney Nepean Hospital, Penrith, Sydney, Australia
| | - Batool Nadim
- Acute Gynecology, Early Pregnancy & Advanced Endoscopic Surgery Unit, Sydney Medical School Nepean, University of Sydney Nepean Hospital, Penrith, Sydney, Australia
| | - Shannon Reid
- Department of Obstetrics & Gynecology, Wollongong Hospital, Wollongong, Australia
| | - Ishwari Casikar
- Acute Gynecology, Early Pregnancy & Advanced Endoscopic Surgery Unit, Sydney Medical School Nepean, University of Sydney Nepean Hospital, Penrith, Sydney, Australia
| | - George Condous
- Acute Gynecology, Early Pregnancy & Advanced Endoscopic Surgery Unit, Sydney Medical School Nepean, University of Sydney Nepean Hospital, Penrith, Sydney, Australia
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15
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Barnhart KT, Sammel MD, Stephenson M, Robins J, Hansen KR, Youssef WA, Santoro N, Eisenberg E, Zhang H. Optimal treatment for women with a persisting pregnancy of unknown location, a randomized controlled trial: The ACT-or-NOT trial. Contemp Clin Trials 2018; 73:145-151. [PMID: 30243810 PMCID: PMC6231403 DOI: 10.1016/j.cct.2018.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/13/2018] [Accepted: 09/18/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Pregnancy of unknown location (PUL) is not a diagnosis but a transient state used to classify a woman when she has a positive pregnancy test without definitive evidence of an intra-uterine or extra-uterine pregnancy on transvaginal ultrasonography. Management of a persisting PUL varies substantially, including expectant or active management. Active management can include uterine cavity evacuation or systemic administration of methotrexate. To date, no consensus has been reached on whether either management strategy is superior or non-inferior to the other. DESIGN Randomized controlled trial. SETTING Academic medical centers. PATIENTS We plan to randomize 276 persisting PUL-diagnosed women who are 18 years or older from Reproductive Medicine Network clinics and additional interested sites, all patients will be followed for 2 years for fertility and patient satisfaction outcomes. INTERVENTIONS Randomization will be 1:1:1 ratio between expectant management, uterine evacuation and empiric use of methotrexate. After randomization to initial management plan, all patients will be followed by their clinicians until resolution of the PUL. The clinician will determine whether there is a change in management, based on clinical symptoms, and/or serial human chorionic gonadotropin (hCG) concentrations and/or additional ultrasonography. MAIN OUTCOME The primary outcome measure in each of the 3 treatment arms is the uneventful clinical resolution of a persistent PUL without change from the initial management strategy. Secondary outcome measures include: number of ruptured ectopic pregnancies, number and type of re-interventions (additional methotrexate injections or surgical procedures), treatment complications, adverse events, number of visits, time to resolution, patient satisfaction, and future fertility. CONCLUSION This multicenter randomized controlled trial will provide guidance for evidence-based management for women who have persisting pregnancy of unknown location.
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MESH Headings
- Female
- Humans
- Pregnancy
- Abortifacient Agents, Nonsteroidal/therapeutic use
- Abortion, Spontaneous/blood
- Abortion, Spontaneous/diagnosis
- Abortion, Spontaneous/diagnostic imaging
- Abortion, Spontaneous/therapy
- Chorionic Gonadotropin/blood
- Diagnosis, Differential
- Dilatation and Curettage
- Methotrexate/therapeutic use
- Pregnancy, Ectopic/blood
- Pregnancy, Ectopic/diagnosis
- Pregnancy, Ectopic/diagnostic imaging
- Pregnancy, Ectopic/therapy
- Ultrasonography
- Watchful Waiting
- Randomized Controlled Trials as Topic
- Multicenter Studies as Topic
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Affiliation(s)
- Kurt T Barnhart
- Department of Obstetrics and Gynecology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States; Department of Biostatistics and Epidemiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Mary D Sammel
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States
| | - Mary Stephenson
- Department of Obstetrics and Gynecology, University of Illinois at Chicago, Chicago, IL, United States
| | - Jared Robins
- Division of Reproductive Endocrinology and Infertility, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Karl R Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences, Oklahoma City, OK, United States
| | - Wahid A Youssef
- Department of Obstetrics and Gynecology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado, Denver, United States
| | - Esther Eisenberg
- Reproductive Sciences Branch, Eunice Kennedy Shriver NICHD, Rockville, MD, United States
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, United States
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16
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Abstract
BACKGROUND Medical management of early pregnancy loss is an alternative to uterine aspiration, but standard medical treatment with misoprostol commonly results in treatment failure. We compared the efficacy and safety of pretreatment with mifepristone followed by treatment with misoprostol with the efficacy and safety of misoprostol use alone for the management of early pregnancy loss. METHODS We randomly assigned 300 women who had an anembryonic gestation or in whom embryonic or fetal death was confirmed to receive pretreatment with 200 mg of mifepristone, administered orally, followed by 800 μg of misoprostol, administered vaginally (mifepristone-pretreatment group), or 800 μg of misoprostol alone, administered vaginally (misoprostol-alone group). Participants returned 1 to 4 days after misoprostol use for evaluation, including ultrasound examination, by an investigator who was unaware of the treatment-group assignments. Women in whom the gestational sac was not expelled were offered expectant management, a second dose of misoprostol, or uterine aspiration. We followed all participants for 30 days after randomization. Our primary outcome was gestational sac expulsion with one dose of misoprostol by the first follow-up visit and no additional intervention within 30 days after treatment. RESULTS Complete expulsion after one dose of misoprostol occurred in 124 of 148 women (83.8%; 95% confidence interval [CI], 76.8 to 89.3) in the mifepristone-pretreatment group and in 100 of 149 women (67.1%; 95% CI, 59.0 to 74.6) in the misoprostol-alone group (relative risk, 1.25; 95% CI, 1.09 to 1.43). Uterine aspiration was performed less frequently in the mifepristone-pretreatment group than in the misoprostol-alone group (8.8% vs. 23.5%; relative risk, 0.37; 95% CI, 0.21 to 0.68). Bleeding that resulted in blood transfusion occurred in 2.0% of the women in the mifepristone-pretreatment group and in 0.7% of the women in the misoprostol-alone group (P=0.31); pelvic infection was diagnosed in 1.3% of the women in each group. CONCLUSIONS Pretreatment with mifepristone followed by treatment with misoprostol resulted in a higher likelihood of successful management of first-trimester pregnancy loss than treatment with misoprostol alone. (Funded by the National Institute of Child Health and Human Development; PreFaiR ClinicalTrials.gov number, NCT02012491 .).
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MESH Headings
- Abortifacient Agents, Nonsteroidal/administration & dosage
- Abortifacient Agents, Nonsteroidal/adverse effects
- Abortifacient Agents, Steroidal/administration & dosage
- Abortifacient Agents, Steroidal/adverse effects
- Abortion, Spontaneous/diagnostic imaging
- Abortion, Spontaneous/drug therapy
- Administration, Intravaginal
- Administration, Oral
- Adult
- Drug Therapy, Combination
- Embryo, Mammalian
- Female
- Fetal Death
- Gestational Sac/diagnostic imaging
- Hemorrhage/chemically induced
- Humans
- Mifepristone/administration & dosage
- Mifepristone/adverse effects
- Misoprostol/administration & dosage
- Misoprostol/adverse effects
- Pregnancy
- Pregnancy Trimester, First
- Ultrasonography
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Affiliation(s)
- Courtney A Schreiber
- From the Pregnancy Early Access Center (PEACE), Division of Family Planning (C.A.S., S.S.), Department of Obstetrics and Gynecology (C.A.S., S.S., K.T.B.), University of Pennsylvania, Philadelphia; the Department of Public Health Sciences, University of Virginia, Charlottesville (S.J.R.); the Department of Obstetrics and Gynecology, University of California, Davis, Sacramento (M.D.C.); and the Department of Obstetrics and Gynecology, Montefiore Hospital and Albert Einstein College of Medicine, Bronx, NY (J.A.)
| | - Mitchell D Creinin
- From the Pregnancy Early Access Center (PEACE), Division of Family Planning (C.A.S., S.S.), Department of Obstetrics and Gynecology (C.A.S., S.S., K.T.B.), University of Pennsylvania, Philadelphia; the Department of Public Health Sciences, University of Virginia, Charlottesville (S.J.R.); the Department of Obstetrics and Gynecology, University of California, Davis, Sacramento (M.D.C.); and the Department of Obstetrics and Gynecology, Montefiore Hospital and Albert Einstein College of Medicine, Bronx, NY (J.A.)
| | - Jessica Atrio
- From the Pregnancy Early Access Center (PEACE), Division of Family Planning (C.A.S., S.S.), Department of Obstetrics and Gynecology (C.A.S., S.S., K.T.B.), University of Pennsylvania, Philadelphia; the Department of Public Health Sciences, University of Virginia, Charlottesville (S.J.R.); the Department of Obstetrics and Gynecology, University of California, Davis, Sacramento (M.D.C.); and the Department of Obstetrics and Gynecology, Montefiore Hospital and Albert Einstein College of Medicine, Bronx, NY (J.A.)
| | - Sarita Sonalkar
- From the Pregnancy Early Access Center (PEACE), Division of Family Planning (C.A.S., S.S.), Department of Obstetrics and Gynecology (C.A.S., S.S., K.T.B.), University of Pennsylvania, Philadelphia; the Department of Public Health Sciences, University of Virginia, Charlottesville (S.J.R.); the Department of Obstetrics and Gynecology, University of California, Davis, Sacramento (M.D.C.); and the Department of Obstetrics and Gynecology, Montefiore Hospital and Albert Einstein College of Medicine, Bronx, NY (J.A.)
| | - Sarah J Ratcliffe
- From the Pregnancy Early Access Center (PEACE), Division of Family Planning (C.A.S., S.S.), Department of Obstetrics and Gynecology (C.A.S., S.S., K.T.B.), University of Pennsylvania, Philadelphia; the Department of Public Health Sciences, University of Virginia, Charlottesville (S.J.R.); the Department of Obstetrics and Gynecology, University of California, Davis, Sacramento (M.D.C.); and the Department of Obstetrics and Gynecology, Montefiore Hospital and Albert Einstein College of Medicine, Bronx, NY (J.A.)
| | - Kurt T Barnhart
- From the Pregnancy Early Access Center (PEACE), Division of Family Planning (C.A.S., S.S.), Department of Obstetrics and Gynecology (C.A.S., S.S., K.T.B.), University of Pennsylvania, Philadelphia; the Department of Public Health Sciences, University of Virginia, Charlottesville (S.J.R.); the Department of Obstetrics and Gynecology, University of California, Davis, Sacramento (M.D.C.); and the Department of Obstetrics and Gynecology, Montefiore Hospital and Albert Einstein College of Medicine, Bronx, NY (J.A.)
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17
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Calì G, Timor-Tritsch IE, Palacios-Jaraquemada J, Monteaugudo A, Buca D, Forlani F, Familiari A, Scambia G, Acharya G, D'Antonio F. Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2018; 51:169-175. [PMID: 28661021 DOI: 10.1002/uog.17568] [Citation(s) in RCA: 141] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 06/16/2017] [Accepted: 06/22/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To explore the outcome in women managed expectantly following the diagnosis of Cesarean scar pregnancy (CSP). METHODS An electronic search of MEDLINE, EMBASE and ClinicalTrials.gov databases was performed utilizing combinations of relevant medical subject headings for 'Cesarean scar pregnancy' and 'outcome'. Reference lists of relevant articles and reviews were hand-searched for additional reports. Observed outcomes included: severe first-trimester vaginal bleeding; clinical symptoms (abdominal pain, vaginal bleeding) requiring treatment; uncomplicated miscarriage; complicated miscarriage requiring intervention; first- or second-trimester uterine rupture or hysterectomy; third-trimester bleeding, uterine rupture or hysterectomy; maternal death; incidence of abnormally invasive placenta (AIP); prevalence of placenta percreta; ultrasound signs suggestive of AIP; and live birth. Meta-analyses of proportions using a random-effects model were used to combine data. Cases were stratified based on the presence or absence of embryonic/fetal heart activity at the time of diagnosis. RESULTS A total of 17 studies (69 cases of CSP managed expectantly, 52 with and 17 without embryonic/fetal heart beat) were included. In women with CSP and embryonic/fetal heart activity, 13.0% (95% CI, 3.8-26.7%) experienced an uncomplicated miscarriage, while 20.0% (95% CI, 7.1-37.4%) required medical intervention. Uterine rupture during the first or second trimester of pregnancy occurred in 9.9% (95% CI, 2.9-20.4%) of cases, while hysterectomy was required in 15.2% (95% CI, 3.6-32.8%) of all cases. Forty (76.9% (95% CI, 65.4-86.5%)) women progressed to the third trimester of pregnancy, of whom 39.2% (95% CI, 15.4-66.2%) experienced severe bleeding. Finally, 74.8% (95% CI, 52.0-92.1%) had a surgical or pathological diagnosis of AIP at delivery and around two-thirds (69.7% (95% CI, 42.8-90.1%)) of them had placenta percreta. In women with CSP but no embryonic/fetal cardiac activity, an uncomplicated miscarriage occurred in 69.1% (95% CI, 47.4-87.1%) of cases, while surgical or medical intervention during or immediately after miscarriage was required in 30.9% (95% CI, 12.9-52.6%). Uterine rupture during the first trimester of pregnancy occurred in 13.4% (95% CI, 2.7-30.3%) of cases, but hysterectomy was not required in any case. CONCLUSIONS CSP with positive embryonic/fetal heart activity managed expectantly is associated with a high burden of maternal morbidity including severe hemorrhage, early uterine rupture, hysterectomy and severe AIP. Despite this, a significant proportion of pregnancies complicated by CSP may progress to, or close to, term, thus questioning whether termination of pregnancy should be the only therapeutic option offered to these women. Expectant management of CSP with no cardiac activity may be a reasonable option in view of the low likelihood of maternal complications requiring intervention, although close surveillance is advisable to avoid adverse maternal outcome. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- G Calì
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - I E Timor-Tritsch
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, New York University School of Medicine, New York, NY, USA
| | - J Palacios-Jaraquemada
- Centre for Medical Education and Clinical Research (CEMIC), University Hospital, Buenos Aires, Argentina
| | - A Monteaugudo
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, New York University School of Medicine, New York, NY, USA
| | - D Buca
- Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - F Forlani
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - A Familiari
- Department of Maternal-Fetal Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - G Scambia
- Department of Maternal-Fetal Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - G Acharya
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
| | - F D'Antonio
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
- Department of Obstetrics and Gynecology, University Hospital of Northern Norway, Tromsø, Norway
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Abstract
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.
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Affiliation(s)
- Aya Kamaya
- Stanford University Medical Center, 300 Pasteur Drive, H1307, Stanford, CA, 94305, USA.
| | - Priya Menon Krishnarao
- Department of Radiology, Santa Clara Valley Medical Center, 751 S. Bascom Ave, San Jose, CA, 95128, USA
| | - Nita Nayak
- Stanford University Medical Center, 300 Pasteur Drive, H1307, Stanford, CA, 94305, USA
| | - R Brooke Jeffrey
- Stanford University Medical Center, 300 Pasteur Drive, H1307, Stanford, CA, 94305, USA
| | - Katherine E Maturen
- Department of Radiology, University of Michigan, 1500 E Med Ctr Dr, UH B1 D530H, Ann Arbor, MI, 48109, USA
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Breeze C. Early pregnancy bleeding. Aust Fam Physician 2016; 45:283-286. [PMID: 27166462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Twenty to forty per cent of pregnant women will experience bleeding during the first trimester. Initial presentation is usually to the general practitioner. Complications of miscarriage, including threatened miscarriage and ectopic pregnancy, are the most common diagnoses. The failure to diagnose an ectopic pregnancy may have life-threatening consequences for a woman. OBJECTIVE The aim of this article is to review the history, examination findings, investigations and management options for miscarriage and ectopic pregnancy. DISCUSSION Early pregnancy bleeding is a very distressing symptom for which a woman seeks reassurance that she has an ongoing pregnancy. It is not always possible to make a diagnosis at the first presentation. In some cases, the need for follow-up investigations or referral to a gynaecologist is required. As healthcare providers, we should continue to review and update our knowledge in the management of this common presentation in order to optimise our care of these patients.
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Yi Y, Lu G, Ouyang Y, lin G, Gong F, Li X. A logistic model to predict early pregnancy loss following in vitro fertilization based on 2601 infertility patients. Reprod Biol Endocrinol 2016; 14:15. [PMID: 27036944 PMCID: PMC4818412 DOI: 10.1186/s12958-016-0147-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 03/04/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND According to previous studies, even after embryonic cardiac activity is detected, the pregnancy loss rate remains 3-4 %. The objectives of this study were to investigate the differences in ultrasound parameters between a miscarriage group and an ongoing pregnancy group during the 1(st) trimester and to build a logistic model to predict early pregnancy loss (EPL) after the appearance of embryonic cardiac activity in patients who have undergone in vitro fertilization embryo transfer (IVF-ET) treatment. METHOD A total of 2601 patients with early singleton pregnancies with embryonic cardiac activity were retrospectively analyzed after IVF from January 2010 to June 2011. Transvaginal sonography (TVS) was performed at 6 to 10 weeks of gestational age (GA). The mean gestational sac diameter (MSD), crown-rump length (CRL), fetal heart rate (FHR), and yolk sac diameter (YSD) were measured by TVS. RESULTS A total of 2400 patients had an ongoing pregnancy and an additional 201 (7.7 %) patients miscarried during the first trimester after fetal cardiac activity had been established. The maternal age (MA) and infertility duration were much greater, and the MSD, CRL, and FHR were much lower in the miscarriage group than in the ongoing pregnancy group after IVF (P < 0.05). The prediction model utilized the following equation: the possibility of EPL = exp(z)/(1 + exp(z)), where z = -21.456 + (0.114 × MA) + (4.305 × × GA) - (0.043 × MSD) - (0.359 × CRL) - (0.091 × FHR) + 2.243 (fluid collection present around the gestational sac (GS)) + 2.519 (when YSD < 3) or - 0.347 (when YSD > 5.5). CONCLUSION The MA, MSD, CRL, YSD, FHR, infertility duration, and fluid collection around the GS were each correlated with EPL after IVF in infertile patients. A logistic model is a useful tool for predicting EPL after the appearance of embryonic cardiac activity (area under the curve [AUC] = 0.909).
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Affiliation(s)
- Yan Yi
- Institute of Reproductive and Stem Cell Engineering, Central South University, Xiangya Road, Changsha, 410078 Hunan P. R. China
| | - Guangxiu Lu
- Institute of Reproductive and Stem Cell Engineering, Central South University, Xiangya Road, Changsha, 410078 Hunan P. R. China
- Reproductive and Genetic Hospital of CITIC-Xiangya, Xiangya Road, Changsha, 410078 Hunan P. R. China
| | - Yan Ouyang
- Institute of Reproductive and Stem Cell Engineering, Central South University, Xiangya Road, Changsha, 410078 Hunan P. R. China
- Reproductive and Genetic Hospital of CITIC-Xiangya, Xiangya Road, Changsha, 410078 Hunan P. R. China
| | - Ge lin
- Institute of Reproductive and Stem Cell Engineering, Central South University, Xiangya Road, Changsha, 410078 Hunan P. R. China
- Reproductive and Genetic Hospital of CITIC-Xiangya, Xiangya Road, Changsha, 410078 Hunan P. R. China
| | - Fei Gong
- Institute of Reproductive and Stem Cell Engineering, Central South University, Xiangya Road, Changsha, 410078 Hunan P. R. China
- Reproductive and Genetic Hospital of CITIC-Xiangya, Xiangya Road, Changsha, 410078 Hunan P. R. China
| | - Xihong Li
- Reproductive and Genetic Hospital of CITIC-Xiangya, Xiangya Road, Changsha, 410078 Hunan P. R. China
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Chaveeva P, Dimitrov I, Yankova M, Stratieva V, Dimitrov T, Shterev A. [Ultrasound Examination and Management of Twin Pregnancy.]. Akush Ginekol (Sofiia) 2016; 55:19-25. [PMID: 29370502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
UNLABELLED Twin pregnancies are found in about 3 % of all pregnancies and 2/3 are dizygotic and 1/3 are monozygotic. In the last 30 years after the introduction of assisted conception and increasing maternal age the rate of twin pregnancies dramatically increased. Compared to singletons, twins have more complications such as intrauterine demise, intrauterine selective fetal growth reStriction, congenital anomalies, miscarriage and preterm labour. Monochorionic twins are at high risk for unique complications because of blood exchange through vascular communications in the shared placenta. Twin pregnancies should be considered as a high risk pregnancies and the well-being of the two fetuses should be taken into account with a strict protocol for follow up and management options. CONCLUSION Ultrasound examination olavs a maior role in fetal surveillance.
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Bourne T, Preisler J, Van Calster B, Timmerman D. Authors' reply to Fountain and colleagues. BMJ 2015; 351:h5852. [PMID: 26537129 DOI: 10.1136/bmj.h5852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Tom Bourne
- Queen Charlotte's and Chelsea Hospital, Imperial College, London W12 0HS, UK
| | - Jessica Preisler
- Queen Charlotte's and Chelsea Hospital, Imperial College, London W12 0HS, UK
| | - Ben Van Calster
- Department of Development and Regeneration, KU Leuven, Belgium
| | - Dirk Timmerman
- Department of Development and Regeneration, KU Leuven, Belgium
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Fountain SA, Dipper M, Smith H. Additional factors to take into account when diagnosing miscarriage. BMJ 2015; 351:h5851. [PMID: 26537252 DOI: 10.1136/bmj.h5851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Wie JH, Choe S, Kim SJ, Shin JC, Kwon JY, Park IY. Sonographic Parameters for Prediction of Miscarriage: Role of 3-Dimensional Volume Measurement. J Ultrasound Med 2015; 34:1777-1784. [PMID: 26324757 DOI: 10.7863/ultra.15.14.09012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 01/07/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To evaluate the value of volume measurement using 3-dimensional sonography for prediction of miscarriage. METHODS We prospectively enrolled 188 singleton pregnant women at 5 to 9 weeks' gestation. The 3-dimensional sonographic gestational sac volume and yolk sac volume were measured together with the fetal heart rate, gestational sac diameter, and yolk sac diameter. For each sonographic parameter, nomograms were created; z scores were calculated for each measurement, and the values were compared between miscarriage and ongoing pregnancy groups. Sonographic parameters for prediction of miscarriage were evaluated by multivariate analysis, and the screening performance was assessed by a receiver operating characteristic curve. RESULTS Among the 188 pregnancies, 30 (16.0%) had miscarriage. Multivariate analysis showed that fetal heart rate below the 5th percentile (odds ratio, 6.43), gestational sac diameter below the 5th percentile (odds ratio, 4.87), gestational sac volume below the 5th percentile (odds ratio, 5.25), and yolk sac diameter below the 2.5th or above the 97.5th percentile (odds ratio, 15.86) were significant predictors of miscarriage (P = .018; P = .018; P = .033; and P < .001, respectively). At a false-positive rate of 30%, the detection rate for miscarriage in screening by a combination of fetal heart rate, gestational sac diameter, gestational sac volume, and yolk sac diameter was 77.8%. CONCLUSIONS A small-for-gestational-age gestational sac volume is a significant sonographic predictor of miscarriage, as are fetal bradycardia, a small gestational sac diameter, and a small or large yolk sac diameter.
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Affiliation(s)
- Jeong Ha Wie
- Department of Obstetrics and Gynecology (J.H.W., S.J.K., J.C.S., J.Y.K., I.Y.P.) and Physiology Laboratory (S.C.), Catholic University of Korea, Seoul, Korea
| | - Suyearn Choe
- Department of Obstetrics and Gynecology (J.H.W., S.J.K., J.C.S., J.Y.K., I.Y.P.) and Physiology Laboratory (S.C.), Catholic University of Korea, Seoul, Korea
| | - Sa Jin Kim
- Department of Obstetrics and Gynecology (J.H.W., S.J.K., J.C.S., J.Y.K., I.Y.P.) and Physiology Laboratory (S.C.), Catholic University of Korea, Seoul, Korea
| | - Jong Chul Shin
- Department of Obstetrics and Gynecology (J.H.W., S.J.K., J.C.S., J.Y.K., I.Y.P.) and Physiology Laboratory (S.C.), Catholic University of Korea, Seoul, Korea
| | - Ji Young Kwon
- Department of Obstetrics and Gynecology (J.H.W., S.J.K., J.C.S., J.Y.K., I.Y.P.) and Physiology Laboratory (S.C.), Catholic University of Korea, Seoul, Korea.
| | - In Yang Park
- Department of Obstetrics and Gynecology (J.H.W., S.J.K., J.C.S., J.Y.K., I.Y.P.) and Physiology Laboratory (S.C.), Catholic University of Korea, Seoul, Korea.
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Preisler J, Kopeika J, Ismail L, Vathanan V, Farren J, Abdallah Y, Battacharjee P, Van Holsbeke C, Bottomley C, Gould D, Johnson S, Stalder C, Van Calster B, Hamilton J, Timmerman D, Bourne T. Defining safe criteria to diagnose miscarriage: prospective observational multicentre study. BMJ 2015; 351:h4579. [PMID: 26400869 PMCID: PMC4580727 DOI: 10.1136/bmj.h4579] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2015] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To validate recent guidance changes by establishing the performance of cut-off values for embryo crown-rump length and mean gestational sac diameter to diagnose miscarriage with high levels of certainty. Secondary aims were to examine the influence of gestational age on interpretation of mean gestational sac diameter and crown-rump length values, determine the optimal intervals between scans and findings on repeat scans that definitively diagnose pregnancy failure.) DESIGN Prospective multicentre observational trial. SETTING Seven hospital based early pregnancy assessment units in the United Kingdom. PARTICIPANTS 2845 women with intrauterine pregnancies of unknown viability included if transvaginal ultrasonography showed an intrauterine pregnancy of uncertain viability. In three hospitals this was initially defined as an empty gestational sac <20 mm mean diameter with or without a visible yolk sac but no embryo, or an embryo with crown-rump length <6 mm with no heartbeat. Following amended guidance in December 2011 this definition changed to a gestational sac size <25 mm or embryo crown-rump length <7 mm. At one unit the definition was extended throughout to include a mean gestational sac diameter <30 mm or embryo crown-rump length <8 mm. MAIN OUTCOME MEASURES Mean gestational sac diameter, crown-rump length, and presence or absence of embryo heart activity at initial and repeat transvaginal ultrasonography around 7-14 days later. The final outcome was pregnancy viability at 11-14 weeks' gestation. RESULTS The following indicated a miscarriage at initial scan: mean gestational sac diameter ≥ 25 mm with an empty sac (364/364 specificity: 100%, 95% confidence interval 99.0% to 100%), embryo with crown-rump length ≥ 7 mm without visible embryo heart activity (110/110 specificity: 100%, 96.7% to 100%), mean gestational sac diameter ≥ 18 mm for gestational sacs without an embryo presenting after 70 days' gestation (907/907 specificity: 100%, 99.6% to 100%), embryo with crown-rump length ≥ 3 mm without visible heart activity presenting after 70 days' gestation (87/87 specificity: 100%, 95.8% to 100%). The following were indicative of miscarriage at a repeat scan: initial scan and repeat scan after seven days or more showing an embryo without visible heart activity (103/103 specificity: 100%, 96.5% to 100%), pregnancies without an embryo and mean gestational sac diameter <12 mm where the mean diameter has not doubled after 14 days or more (478/478 specificity: 100%, 99.2% to 100%), pregnancies without an embryo and mean gestational sac diameter ≥ 12 mm showing no embryo heartbeat after seven days or more (150/150 specificity: 100%, 97.6% to 100%). CONCLUSIONS Recently changed cut-off values of gestational sac and embryo size defining miscarriage are appropriate and not too conservative but do not take into account gestational age. Guidance on timing between scans and expected findings on repeat scans are still too liberal. Protocols for miscarriage diagnosis should be reviewed to account for this evidence to avoid misdiagnosis and the risk of terminating viable pregnancies.
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Affiliation(s)
- Jessica Preisler
- Queen Charlotte's and Chelsea Hospital, Imperial College, London W12 0HS, UK
| | - Julia Kopeika
- Early Pregnancy and Acute Gynaecology Unit, St Thomas' Hospital, London, UK
| | - Laure Ismail
- Queen Charlotte's and Chelsea Hospital, Imperial College, London W12 0HS, UK St Mary's Hospital, Imperial College NHS Trust, London, UK
| | | | - Jessica Farren
- Queen Charlotte's and Chelsea Hospital, Imperial College, London W12 0HS, UK
| | - Yazan Abdallah
- Queen Charlotte's and Chelsea Hospital, Imperial College, London W12 0HS, UK
| | | | - Caroline Van Holsbeke
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | | | - Deborah Gould
- St Mary's Hospital, Imperial College NHS Trust, London, UK
| | | | - Catriona Stalder
- Queen Charlotte's and Chelsea Hospital, Imperial College, London W12 0HS, UK
| | - Ben Van Calster
- Department of Development and Regeneration, KU Leuven, Belgium
| | - Judith Hamilton
- Early Pregnancy and Acute Gynaecology Unit, St Thomas' Hospital, London, UK
| | - Dirk Timmerman
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium Department of Development and Regeneration, KU Leuven, Belgium
| | - Tom Bourne
- Queen Charlotte's and Chelsea Hospital, Imperial College, London W12 0HS, UK Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium Department of Development and Regeneration, KU Leuven, Belgium
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Affiliation(s)
- Elizabeth Anne McCarthy
- University of Melbourne, Department of Obstetrics and Gynaecology at Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Stephen Tong
- University of Melbourne, Department of Obstetrics and Gynaecology at Mercy Hospital for Women, Heidelberg, Victoria, Australia
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Helmy S, Mavrelos D, Sawyer E, Ben-Nagi J, Koch M, Day A, Jurkovic D. Serum Human Chorionic Gonadotropin (β- hCG) Clearance Curves in Women with Successfully Expectantly Managed Tubal Ectopic Pregnancies: A Retrospective Cohort Study. PLoS One 2015; 10:e0130598. [PMID: 26135923 PMCID: PMC4489732 DOI: 10.1371/journal.pone.0130598] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 05/21/2015] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To establish clearance curves for serum β -hCG in women with successfully expectantly managed tubal ectopic pregnancies. DESIGN Retrospective cohort study. Non- viable tubal ectopic pregnancy was diagnosed on transvaginal ultrasound. If initial serum β hCG was less than 5000 IU/L and patients were asymptomatic, expectant management was offered. Patients underwent serial β hCG measurements until serum β hCG was less than 20 IU/l, or the urine pregnancy test was negative. SETTING Early Pregnancy and Gynaecology Assessment Unit, Kings College Hospital, London (December 1998 to July 2006). PATIENTS We included 161 women with diagnosed non-viable tubal ectopic pregnancy who underwent successful expectant management. MAIN OUTCOME MEASURE Serum β hCG level. RESULTS Mean initial serum β- hCG was 488 IU/L (41 - 4883) and median serum β hCG clearance time was 19 days (5 - 82). The average half-life of β hCG clearance was 82.5 hours (±SD 50.2) in patients with steadily declining serum β- hCG levels compared to 106.7 hours (±SD 72.0) in patients with primarily plateauing β-hCG levels in the declining phase. However, these differences were not significant (p>0.05). CONCLUSION We identified a median follow-up of 19 days until serum β hCG clearance in women with tubal ectopic pregnancy and successful expectant management. Although non- significant, women with initially plateauing serum β hCG showed a longer follow-up time until clearance compared to women with steadily declining β hCG levels. This information may serve as a guideline enabling clinicians to predict the length of follow-up for women with tubal ectopic pregnancy and expectant management.
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MESH Headings
- Abortion, Spontaneous/blood
- Abortion, Spontaneous/diagnosis
- Abortion, Spontaneous/diagnostic imaging
- Abortion, Spontaneous/pathology
- Adolescent
- Adult
- Biomarkers/blood
- Chorionic Gonadotropin, beta Subunit, Human/blood
- Female
- Half-Life
- Humans
- Pregnancy
- Pregnancy, Tubal/blood
- Pregnancy, Tubal/diagnosis
- Pregnancy, Tubal/diagnostic imaging
- Pregnancy, Tubal/pathology
- Retrospective Studies
- Ultrasonography
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Affiliation(s)
- Samir Helmy
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
- Early Pregnancy and Gynaecology Assessment Unit, King’s College Hospital, London, United Kingdom
| | - Dimitrios Mavrelos
- Early Pregnancy and Gynaecology Assessment Unit, King’s College Hospital, London, United Kingdom
| | - Elinor Sawyer
- Early Pregnancy and Gynaecology Assessment Unit, King’s College Hospital, London, United Kingdom
| | - Jara Ben-Nagi
- Early Pregnancy and Gynaecology Assessment Unit, King’s College Hospital, London, United Kingdom
| | - Marianne Koch
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
- Karl Landsteiner Society, Vienna, Austria
| | - Andrea Day
- Gynaecology Diagnostic and Outpatient Treatment Unit, University College Hospitals London (UCL), London, United Kingdom
| | - Davor Jurkovic
- Gynaecology Diagnostic and Outpatient Treatment Unit, University College Hospitals London (UCL), London, United Kingdom
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Hu M, Poder L, Filly RA. Impact of new society of radiologists in ultrasound early first-trimester diagnostic criteria for nonviable pregnancy. J Ultrasound Med 2014; 33:1585-1588. [PMID: 25154939 DOI: 10.7863/ultra.33.9.1585] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES New early first-trimester diagnostic criteria for nonviable pregnancy recommended by the Society of Radiologists in Ultrasound via a multispecialty consensus panel extended the diagnostic size criteria of crown-rump length from 5 to 7 mm for embryos without a heartbeat and mean sac diameter from 16 to 25 mm for "empty" sacs. Our study assessed the potential impact of the new criteria on the number of additional follow-up sonograms these changes would engender. METHODS A retrospective study of all first-trimester sonograms in women with first trimester bleeding from 1999 to 2008 was conducted. Everyone included in the study had a visible gestational sac in the uterus. There were no pregnancies of unknown location or ectopic pregnancies included in this study cohort. Pregnancy of unknown location was used to describe cases in which there were no signs of pregnancy inside or outside the uterus on transvaginal sonography despite a positive pregnancy test result. A total of 1013 patients met the inclusion criteria. RESULTS Seven hundred fifty-two patients (74%) had identifiable embryos, and 261 (26%) did not. Of those with an identifiable embryo, 286 (38%) had no detectable embryonic cardiac activity. The breakdown of crown-rump lengths in this group was as follows: 100 measuring less than 5 mm, 36 measuring 5 to 7 mm, and 150 measuring 7 mm or greater. The breakdown of mean sac diameters in those without a visible embryo was as follows: 120 measuring less than 16 mm, 90 measuring 16 to 25 mm, and 51 measuring 25 mm or greater. CONCLUSIONS When diagnosing a failed pregnancy, there can be no room for error. Only 126 of 1013 early pregnancies threatening to abort (12%) fell into the more conservative zones defined by the new compared to the former size criteria (crown-rump length, 5-7 mm; mean sac diameter, 16-25 mm). Therefore, the potential impact of the new guidelines on follow-up sonograms does not appear inordinate.
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Affiliation(s)
- Maowen Hu
- Department of Radiology, University of California, San Francisco, California USA
| | - Liina Poder
- Department of Radiology, University of California, San Francisco, California USA.
| | - Roy A Filly
- Department of Radiology, University of California, San Francisco, California USA
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Abstract
AIMS To examine whether misoprostol treatment for first trimester missed abortion affects future fertility. PATIENTS AND METHODS In a historical prospective approach, we analyzed our database for patients treated with misoprostol. All eligible patients underwent an interview according to a questionnaire, which includes their demographic characteristics, obstetric, gynecologic and infertility history. They were asked about the side effects, intention and subsequent ability to conceive. Their future pregnancy rates were calculated and compared to the acceptable figures in the literature. RESULTS The infertility rates among our patients were similar to those reported in the general population. Pregnancy rates 2 years after treatment were similar to the previously published reports, except for lower rates during the first three months post-treatment. Although no between-group differences were observed in the subsequent pregnancy rates, 2 years following misoprostol treatment in ≤35 versus >35 years old patients, primi- versus multigravida and nulli- versus parous women, higher pregnancy rates were observed in patients ≤35 versus >35 years old, primi- versus multigravida and nulli- versus, parous, during the first 3 months following misoprostol treatment. CONCLUSION Misoprostol treatment, for women with first trimester missed abortion and favorable reproductive history, is an acceptable treatment with no detrimental effect on future fertility.
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Affiliation(s)
- Ilia Bord
- Department of Obstetrics and Gynecology, Barzilai Medical Center , Ashkelon , Israel and
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Tan S, Gülden Tangal N, Kanat-Pektas M, Sirin Özcan A, Levent Keskin H, Akgündüz G, Akif Teber M, Arslan H. Abnormal sonographic appearances of the yolk sac: which can be associated with adverse perinatal outcome? Med Ultrason 2014; 16:15-20. [PMID: 24567919 DOI: 10.11152/mu.2014.2066.161.st1gt2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
AIMS The present study aimed to determine whether yolk sacs with abnormal sonographic appearance are associated with adverse perinatal outcomes in both early and late gestation. MATERIAL AND METHODS A total of 305 viable singleton pregnancies with gestational age of 6 to 9 weeks were prospectively evaluated with respect to perinatal outcomes and sonographic characteristics of the yolk sacs. RESULTS An abnormal yolk sac was found in 66 pregnancies. In pregnancies with enlarged yolk sacs a miscarriage occurred in 37.5% of cases (3/8). The pregnancies with a yolk sac diameter >/= 5 mm had a significantly higher risk of miscarriage (p = 0.005). The risk of miscarriage was statistically similar between the pregnancies with regular and those with irregular yolk sacs (p = 0.73). Miscarriage occurred in 3.8% of pregnancies with irregular yolk sacs (2/52) and none of pregnancies with echogenic yolk sacs (0/6). Adverse perinatal outcomes were not associated with either irregular or echogenic yolk sacs. CONCLUSIONS An enlarged yolk sac visualized before the 7th week of gestation is strongly associated with a significantly increased risk for spontaneous miscarriage. The presence of an echogenic or irregular yolk sac appears to be unrelated to adverse perinatal outcome.
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Affiliation(s)
- Sinan Tan
- Ankara Atatürk Education and Research Hospital, Department of Radiology, Ankara, Turkey, E-mail:
| | - Nuray Gülden Tangal
- Ankara Atatürk Education and Research Hospital, Department of Radiology, Ankara, Turkey
| | - Mine Kanat-Pektas
- Afyon Kocatepe University Medical Faculty Hospital, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Ayşenur Sirin Özcan
- Ankara Atatürk Education and Research Hospital, Department of Radiology, Ankara, Turkey
| | - Hüseyin Levent Keskin
- Ankara Atatürk Education and Research Hospital, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Gökçe Akgündüz
- Ankara Atatürk Education and Research Hospital, Department of Radiology, Ankara, Turkey
| | - Mehmet Akif Teber
- Etlik Ihtisas Research and Education Hospital, Department of Radiology4, Ankara, Turkey
| | - Halil Arslan
- Ankara Atatürk Education and Research Hospital, Department of Radiology, Ankara, Turkey
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Feng Z, Jiale Q, Xiaofei Z, Qingyun G, Lili H. Simultaneous osseous metaplasia nodules of the submucosa and mesosalpinx after first trimester abortion: a case report. Eur J Med Res 2013; 18:47. [PMID: 24245923 PMCID: PMC4176990 DOI: 10.1186/2047-783x-18-47] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 10/29/2013] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Here, we report a case of simultaneous osseous metaplasia nodules of the submucosa and mesosalpinx after a first trimester abortion. CASE PRESENTATION A 36-year-old woman presented to the Women's Hospital, School of Medicine, Zhejiang University with vaginal bleeding and infertility resulting from osseous metaplasia nodules of the submucosa and mesosalpinx after a first trimester abortion. Diagnostic and operative hysteroscopy and laparoscope procedures were performed. The osseous metaplasia nodules disappeared after hysteroscopy and laparoscope interventions; 2 weeks postoperatively, the patient underwent a transvaginal ultrasound examination and the abnormal ultrasound appearance had resolved. CONCLUSIONS Osseous metaplasia nodules in the submucosa and mesosalpinx can be a rare cause of vaginal bleeding and infertility. Autologous tissue, not persistent heterologous tissue, may be the true reason for metaplasia. Treatment is by ultrasound-guided curettage or by hysteroscopic and laparoscope removal.
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Affiliation(s)
- Zhou Feng
- Department of Pathology, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Qin Jiale
- Department of Ultrasound, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Zhang Xiaofei
- Department of Pathology, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Guo Qingyun
- Department of Obstetrics and Gynecology, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou, 1 Xueshi Road, Hangzhou, Zhejiang Province 310006, People’s Republic of China
| | - Huang Lili
- Department of Obstetrics and Gynecology, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou, 1 Xueshi Road, Hangzhou, Zhejiang Province 310006, People’s Republic of China
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Abstract
Uterine arteriovenous malformation (AVM) is a little known condition of which, to date, very few cases have been described. It has a very diverse symptomatology, even though in most cases, it is diagnosed during a severe and acute haemorrhagic event. Its treatment can vary from expectant management to hysterectomy; however, current evidence suggests that the embolisation of uterine arteries is the most effective approach, especially if fertility is to be preserved. We present a case report classified as AVM, with additional images that show the appearance of this pathology in a short span of time. This case has a number of peculiarities: unusual persistence of human chorionic gonadotropin hormone (β-HCG), asymptomatic patient, quick establishment of the lesion and its duration with unchanging characteristics and finally its spontaneous resolution without further consequences. This entity shows an aetiopathogenesis, that is, not well established or described. We discuss its physiopathology and aetiopathogenesis.
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Affiliation(s)
- Francisco Sellers
- Department of Obstetrics, Bernabeu Institute, Alicante, Alicante, Spain
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33
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Abstract
The evolution of the diagnosis and management of women with an early pregnancy loss has been a success story. The mortality from ectopic pregnancy has objectively been decreased in the past few decades. However, modern management has resulted in a new set of issues. Over-interpretation of a single ultrasound, misunderstanding of the utility of serial hCG values, and inappropriate use of methotrexate can result in iatrogenic complications. Modern management has successfully improved the diagnosis of ectopic pregnancy before rupture; it should now also focus on ensuring that an intrauterine pregnancy is not interrupted as a result of diagnosis and treatment. This article reviews some of the pitfalls of the modern management of early pregnancy failure and introduces a series of articles on the subject.
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MESH Headings
- Abortifacient Agents, Nonsteroidal/adverse effects
- Abortion, Spontaneous/blood
- Abortion, Spontaneous/diagnosis
- Abortion, Spontaneous/diagnostic imaging
- Abortion, Spontaneous/mortality
- Abortion, Spontaneous/therapy
- Abortion, Therapeutic/adverse effects
- Abortion, Therapeutic/methods
- Biomarkers/blood
- Chorionic Gonadotropin/blood
- Diagnosis, Differential
- Diagnostic Errors
- Early Diagnosis
- Female
- Humans
- Methotrexate/adverse effects
- Predictive Value of Tests
- Pregnancy
- Pregnancy Outcome
- Pregnancy, Ectopic/blood
- Pregnancy, Ectopic/diagnosis
- Pregnancy, Ectopic/diagnostic imaging
- Pregnancy, Ectopic/mortality
- Pregnancy, Ectopic/therapy
- Prenatal Diagnosis/methods
- Risk Assessment
- Risk Factors
- Treatment Outcome
- Ultrasonography, Prenatal
- Unnecessary Procedures
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Affiliation(s)
- Kurt T Barnhart
- Departments of Obstetrics and Gynecology and Epidemiology, Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
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Zwierzchowska A, Głuszak M, Jabiry-Zieniewicz Z, Banaszek-Wysoczańska A, Dziadecki W, Barcz E. [Assessment of efficacy and safety of medical treatment of non-viable first trimester pregnancy]. Ginekol Pol 2012; 83:760-765. [PMID: 23383562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
OBJECTIVES The aim of our study was to assess the efficacy and safety of medical treatment of non-viable first trimester pregnancy. MATERIAL AND METHODS We analyzed 50 cases of women diagnosed with non-viable first trimester pregnancy: missed abortion (79.6%) or anembryonic pregnancy (20.4%), who were admitted and treated at the First Clinic of Obstetrics and Gynecology Medical University of Warsaw, between June 2011 and February 2012. The diagnosis was made after two ultrasound examinations, performed at least one week apart. None of the patients manifested symptoms of imminent miscarriage. All women received medical treatment - misoprostol administered vaginally or in cases of excessive bleeding in the course of the procedure, sublingually - according to our own scheme. The patients were informed that any moment they could decide to discontinue medical treatment and ask for surgery Initially, 4 tablets containing misoprostol (800 mcg) were administered vaginally A control ultrasound examination was performed 6 hours later. If expulsion of the gestational sac was completed, the patient was discharged. If the gestational sac was still present in the uterus, an additional dose of misoprostol was administered: 4 tablets vaginally or if excessive bleeding occurred, 3 tablets (600 mcg) sublingually. Another ultrasound examination was performed after 6 hours from the second dose and the patient was discharged if the expulsion of the gestational sac was completed. If the procedure failed, it was repeated in the same manner the next day. D&C was performed in cases of excessive bleeding, failure of medical treatment after 48 hours, patient decision to discontinue medical treatment or suspected incomplete abortion after menstrual bleeding. For women who completed the medical treatment, control visits were scheduled 14 days after hospital discharge and after menstrual bleeding, if incomplete abortion was suspected. RESULTS D&C was performed in 12% of patients because of failure of medical treatment after 48 hours, excessive bleeding or incomplete abortion after menstrual bleeding. Additional 6% of women decided to discontinue medical treatment and demanded D&C before completing 48 hours of treatment. The mean dose of misoprostol administered until the expulsion of the gestational sac was 1.404 g (7.02 tablets). In 60% of cases the expulsion was completed before 12 hours from the beginning of the procedure. In multiparae, the time until expulsion did not exceed 6 hours more frequently than in nulliparae (50 vs. 24.14%, p<0.05). The duration of the procedure did not exceed 24 hours in any of the multiparae. Among women who did not undergo D&C, 46.2% were diagnosed with complete abortion during the control visit, 74 days after the hospital discharge, and 53.8%- after menstrual bleeding. No serious side effects of misoprostol, influencing its safety, were observed. CONCLUSIONS Medical treatment is a highly effective and safe method of management of non-viable first trimester pregnancy. Because of the currently existing variety of protocols, it is recommended to implement standard schemes of misoprostol administration and control visits. It seems that there is no need for hospitalization during the procedure. Outpatient care may contribute to further reduction of the D&C rate. Limited surgery rate, apart from decreasing the risk of iatrogenic damage of the uterus, additionally leads to lower treatment costs as it eliminates the necessity of hospitalization and anesthesia.
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Affiliation(s)
- Aneta Zwierzchowska
- I Klinika Połoznictwa i Ginekologii Warszawskiego Uniwersytetu Medycznego, Warszawa, Polska
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Odeh M, Ophir E, Grinin V, Tendler R, Kais M, Bornstein J. Prediction of abortion using three-dimensional ultrasound volumetry of the gestational sac and the amniotic sac in threatened abortion. J Clin Ultrasound 2012; 40:389-393. [PMID: 22806959 DOI: 10.1002/jcu.21957] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2011] [Accepted: 05/07/2012] [Indexed: 06/01/2023]
Abstract
PURPOSE To determine whether gestational sac volume (GSV) or amniotic sac volume (ASV) and/or the difference between them can predict abortion in women with first-trimester threatened abortion. METHODS Ninety patients between 6 and 12 weeks of gestation presenting with vaginal bleeding were studied. Seventy-six delivered after 24 weeks of gestation (group A) and 14 aborted before 20 weeks of gestation (group B). All patients had a singleton viable pregnancy demonstrated by transvaginal ultrasound. Gestational sac and amniotic sac volumes were measured in all the patients using three-dimensional transvaginal ultrasound with Virtual Organ Computer-aided Analysis software, and the gestational sac volume - amniotic sac volume (GSV - ASV) was calculated. RESULTS The groups did not differ in terms of age, parity, number of previous abortions, or term deliveries. The GSV (group A: mean 32.0 ± 27.7 cm(3) ; group B: 26.7 ± 29.1 cm(3) ) and the ASV (group A: 21.1 ± 25.5 cm(3) ; group B: 20.6 ± 26.0 cm(3) ) were not statistically different, while the GSV - ASV was significantly smaller in group B (aborting before week 20) (group A: 10.9 ± 10.9 cm(3) ; group B: 6.1 ± 8.6 cm(3) ; p < 0.05). Using receiver operator curves, the area under the curve for predicting normal pregnancy outcome of the GSV - ASV measurement was 0.654. When the GSV - ASV was 1.8 cm(3) or less, abortion was predicted with 84% sensitivity and 43% specificity. CONCLUSIONS The measurement of the GSV and the ASV are not good predictors of abortion in patients with first-trimester vaginal bleeding, whereas the use of the GSV - ASV may be helpful in predicting the outcome of pregnancy.
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Affiliation(s)
- Marwan Odeh
- Department of Obstetrics and Gynecology, Western Galilee Hospital, Nahariya, Israel
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36
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Devane D. Expectant care versus surgical treatment for miscarriage. Pract Midwife 2012; 15:40-41. [PMID: 22908503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The aim of this bi-monthly column is to highlight Cochrane Systematic Reviews of relevance to pregnancy and childbirth and to stimulate discussion on the relevance and implications of the review for practice. The Cochrane Collaboration is an international organisation that prepares and maintains high quality systematic reviews to help people make well-informed decisions about healthcare and health policy. A systematic review tries to search for, appraise and synthesise existing research to answer a specific research question. The Cochrane Database of Systematic Reviews (CDSR) is published monthly online. Residents in countries with a national license to The Cochrane Library, including the UK and Ireland, can access the Cochrane Library online free through www.thecochranelibrary.com.
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Affiliation(s)
- Declan Devane
- School of Nursing and Midwifery, National University of Ireland Galway
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37
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Abstract
BACKGROUND Miscarriage is a common complication of early pregnancy that can have both medical and psychological consequences such as depression and anxiety. The need for routine surgical evacuation with miscarriage has been questioned because of potential complications such as cervical trauma, uterine perforation, hemorrhage, or infection. OBJECTIVES To compare the safety and effectiveness of expectant management versus surgical treatment for early pregnancy failure. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (9 February 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 4 of 4), PubMed (2005 to 11 January 2012), POPLINE (inception to 11 January 2012), LILACS (2005 to 11 January 2012) and reference lists of retrieved studies. SELECTION CRITERIA Randomized trials comparing expectant care and surgical treatment (vacuum aspiration or dilation and curettage) for miscarriage were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors assessed trial quality and extracted data. We contacted study authors for additional information. For dichotomous data, we calculated the Mantel-Haenszel risk ratio (RR) with 95% confidence interval (CI). For continuous data, we computed the mean difference (MD) and 95% CI. We entered additional data such as medians into 'Other data' tables. MAIN RESULTS We included seven trials with 1521 participants in this review. The expectant-care group was more likely to have an incomplete miscarriage by two weeks (RR 3.98; 95% CI 2.94 to 5.38) or by six to eight weeks (RR 2.56; 95% CI 1.15 to 5.69). The need for unplanned surgical treatment was greater for the expectant-care group (RR 7.35; 95% CI 5.04 to 10.72). The mean percentage needing surgical management in the expectant-care group was 28%, while 4% of the surgical-treatment group needed additional surgery. The expectant-care group had more days of bleeding (MD 1.59; 95% CI 0.74 to 2.45). Further, more of the expectant-care group needed transfusion (RR 6.45; 95% CI 1.21 to 34.42). The mean percentage needing blood transfusion was 1.4% for expectant care compared with none for surgical management. Results were mixed for pain. Diagnosis of infection was similar for the two groups (RR 0.63; 95% CI 0.36 to 1.12), as were results for various psychological outcomes. Pregnancy data were limited. Costs were lower for the expectant-care group (MD -499.10; 95% CI -613.04 to -385.16; in UK pounds sterling). AUTHORS' CONCLUSIONS Expectant management led to a higher risk of incomplete miscarriage, need for unplanned (or additional) surgical emptying of the uterus, bleeding and need for transfusion. Risk of infection and psychological outcomes were similar for both groups. Costs were lower for expectant management. Given the lack of clear superiority of either approach, the woman's preference should be important in decision making. Pharmacological ('medical') management has added choices for women and their clinicians and has been examined in other reviews.
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Affiliation(s)
- Kavita Nanda
- Clinical Sciences, FHI, Research Triangle Park, North Carolina, USA.
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38
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Jurkovic D. Re: limitations of current definitions of miscarriage using mean gestational sac diameter and crown-rump length measurements: a multicenter observational study. Ultrasound Obstet Gynecol 2012; 39:361-362. [PMID: 22535629 DOI: 10.1002/uog.11107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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39
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Ross JA, Johns J. Re: limitations of current definitions of miscarriage using mean gestational sac diameter and crown-rump length measurements: a multicenter observational study. Ultrasound Obstet Gynecol 2012; 39:362-365. [PMID: 22535631 DOI: 10.1002/uog.11106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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40
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O'Dwyer V, Monaghan B, Fattah C, Farah N, Kennelly MM, Turner MJ. Miscarriage after sonographic confirmation of an ongoing pregnancy in women with moderate and severe obesity. Obes Facts 2012; 5:393-8. [PMID: 22797366 DOI: 10.1159/000336253] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Accepted: 12/19/2011] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To compare the incidence of spontaneous miscarriage in women with moderate to severe obesity to that in women with a normal BMI after sonographic confirmation of the foetal heart rate in the first trimester. METHODS Women were enrolled in a prospective observational study at their convenience in the first trimester after an ultrasound confirmed an ongoing singleton pregnancy with foetal heart activity present. Maternal height and weight were measured digitally and BMI was calculated. RESULTS In the 3,000 women enrolled, the miscarriage rate overall was 3.9% (n = 117). The mean gestational age at enrolment was 11.1 weeks. In the class 2-3 (BMI > 34.9 kg/m(2)) obese primigravidas the miscarriage rate was 11.3% (n = 8) compared with 2.7% (n = 24) in the normal BMI category (p = 0.003), and 3.7% (n = 5) in the class 1 obese category (not significant). In multigravidas, there was no increased rate of miscarriage among class 2-3 obese women compared with multigravidas in the normal BMI category. The mean body composition values showed that primigravidas who miscarried had both increased fat and fat-free masses compared with those who did not, but multigravidas who miscarried had a similar fat mass and fat-free mass with those who did not. CONCLUSIONS In women with sonographic evidence of foetal heart activity in the first trimester, the rate of spontaneous miscarriage is low. It was increased in moderate to severely obese primigravidas, but was not increased in other obese women compared to women in the normal BMI category.
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Affiliation(s)
- Vicky O'Dwyer
- UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Dublin, Ireland.
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41
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Affiliation(s)
- Andrew Moscrop
- Department of Primary Health Care, University of Oxford.
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42
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Vaknin Z, Sadeh-Mefpechkin D, Halperin R, Altshuler A, Amir P, Maymon R. Pregnancy-related uterine arteriovenous malformations: experience from a single medical center. Ultraschall Med 2011; 32 Suppl 2:E92-E99. [PMID: 21614746 DOI: 10.1055/s-0031-1273274] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
PURPOSE The purpose of this article was to investigate clinical ultrasonographic findings and the outcomes of post-pregnancy patients with acquired uterine vascular abnormalities including arteriovenous malformations (AVMs). MATERIALS AND METHODS We performed a computerized database search for all patients with ultrasonographic findings of a vascular abnormality including AVM in our referral center between 2000-2008. An ultrasound finding of vascular abnormality was defined as an area of strong hypervascularity within the myometrium and the presence of marked turbulence. The inclusion criteria for angiography were abnormal vaginal bleeding in a hemodynamically stable patient, bhCG serum levels ≤ 30 mIU/ml, and ultrasound demonstration of large (≥ 15 mm on the larger side of the vessel) or multiple vascular lesions. RESULTS 16 women were identified, of whom 10 (63 %) underwent uterine artery embolization. Angiography confirmed the pre-interventional ultrasound diagnosis of AVM in all cases. AVM feeding arteries were on the left side of the uterus in 80 % of the cases. Residual tissue was ultrasonographically detected in five patients: 2 underwent hysteroscopy and guided curettage following embolization and three received methotrexate. All tissue samples were benign. One small vascular abnormality resolved spontaneously. CONCLUSION An acquired uterine vascular abnormality including AVM should be considered in the work-up of post-pregnancy vaginal bleeding.
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Affiliation(s)
- Z Vaknin
- Department of Obstetrics and Gynecology Assaf Harofe Medical Center, Zerifin, Israel
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Abdallah Y, Daemen A, Kirk E, Pexsters A, Naji O, Stalder C, Gould D, Ahmed S, Guha S, Syed S, Bottomley C, Timmerman D, Bourne T. Limitations of current definitions of miscarriage using mean gestational sac diameter and crown-rump length measurements: a multicenter observational study. Ultrasound Obstet Gynecol 2011; 38:497-502. [PMID: 21997898 DOI: 10.1002/uog.10109] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/29/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVES There is significant variation in cut-off values for mean gestational sac diameter (MSD) and embryo crown-rump length (CRL) used to define miscarriage, values suggested in the literature ranging from 13 to 25 mm for MSD and from 3 to 8 mm for CRL. We aimed to define the false-positive rate (FPR) for the diagnosis of miscarriage associated with different CRL and MSD measurements with or without a yolk sac in a large study population of patients attending early pregnancy clinics. We also aimed to define cut-off values for CRL and MSD that, on the basis of a single measurement, can definitively diagnose a miscarriage and so exclude possible inadvertent termination of pregnancy. METHODS This was an observational cross-sectional study. Data were collected prospectively according to a predefined protocol. Intrauterine pregnancy of uncertain viability (IPUV) was defined as an empty gestational sac or sac with a yolk sac but no embryo seen with MSD < 20 or < 30 mm or an embryo with an absent heartbeat and CRL < 6 mm or < 8 mm. We recruited to the study 1060 consecutive women with IPUV. The endpoint was presence or absence of a viable pregnancy at the time of first-trimester screening ultrasonography between 11 and 14 weeks. The sensitivity, specificity, positive and negative predictive values were calculated for potential cut-off values to define miscarriage from MSD 8 to 30 mm with or without a yolk sac and from CRL 3 to 8 mm. RESULTS Of the 1060 women with a diagnosis of IPUV, 473 remained viable and 587 were non-viable by the time of the 11-14-week scan. In the absence of both embryo and yolk sac, the FPR for miscarriage was 4.4% when an MSD cut-off of 16 mm was used and 0.5% for a cut-off of 20 mm. There were no false-positive test results for miscarriage when a cut-off of MSD ≥ 21 mm was used. If a yolk sac was present but an embryo was not, the FPR for miscarriage was 2.6% for an MSD cut-off of 16 mm and 0.4% for a cut-off of 20 mm, with no false-positive results when a cut-off of MSD ≥ 21 mm was used. When an embryo was visible with an absent heartbeat, using a CRL cut-off of 4 mm the FPR for miscarriage was 8.3%, and for a CRL cut-off of 5 mm it was also 8.3%. There were no false-positive results using a CRL cut-off of ≥ 5.3 mm. CONCLUSIONS These data show that some current definitions used to diagnose miscarriage are potentially unsafe. Current national guidelines should be reviewed to avoid inadvertent termination of wanted pregnancies. An MSD cut-off of > 25 mm and a CRL cut-off of > 7 mm could be introduced to minimize the risk of a false-positive diagnosis of miscarriage.
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Affiliation(s)
- Y Abdallah
- Institute of Reproductive and Developmental Biology (IRDB), Imperial College London, London, UK.
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Abdallah Y, Daemen A, Guha S, Syed S, Naji O, Pexsters A, Kirk E, Stalder C, Gould D, Ahmed S, Bottomley C, Timmerman D, Bourne T. Gestational sac and embryonic growth are not useful as criteria to define miscarriage: a multicenter observational study. Ultrasound Obstet Gynecol 2011; 38:503-509. [PMID: 21858883 DOI: 10.1002/uog.10075] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/11/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVES We studied changes in mean gestational sac diameter (MSD) and embryonic crown-rump length (CRL) in intrauterine pregnancies of uncertain viability (IPUVs). We aimed to establish cut-off values for MSD and CRL growth that could be definitively associated with either viability or miscarriage, and to establish the relationship between growth in MSD and appearance of embryonic structures in the gestational sac. METHODS One thousand and sixty consecutive IPUVs were recruited prospectively from four London University hospitals: 462 with no yolk sac or embryo, 419 with a yolk sac but no embryo, and 179 with an embryo but no heartbeat visible. IPUV was defined as an empty gestational sac with or without a yolk sac but no embryo seen with MSD < 20 or < 30 mm (depending on center) or an embryo with no heartbeat and CRL < 6 mm or < 8 mm (depending on center). Scans were repeated 7-14 days later. The endpoint was viability at first-trimester screening ultrasonography between 11 and 14 weeks. Change in MSD and CRL between the first and second scans of each pregnancy was compared with respect to viability and appearance of embryonic structures using the two-sample t-test. RESULTS The study included 359 pregnancies in which a gestational sac with or without embryo was identified at the follow-up scan 7-14 days later. Of these, 192 were viable and 167 non-viable at the 11-14-week scan. MSD growth was significantly higher in viable than non-viable pregnancies (mean 1.003 vs. 0.503 mm/day; P < 0.001, 95% CI of difference 0.403-0.596). A difference in CRL growth was found between the two groups (mean 0.673 vs. 0.148 mm/day; P < 0.001, 95% CI of difference 0.345-0.703). MSD growth of 0.6 mm/day was associated with a specificity for diagnosing miscarriage of 90.1%, a sensitivity of 61.7% and 19 false-positive test results. A cut-off of CRL growth rate of 0.2 mm/day gave a sensitivity of 76.3% and there were no false-positive test results for miscarriage. On repeat scan the failure of either a yolk sac or embryo to be visualized was always associated with miscarriage. CONCLUSION There is an overlap in MSD growth rates between viable and non-viable IPUV. No cut-off exists for MSD growth below which a viable pregnancy could be safely excluded. A cut-off value for CRL growth of 0.2 mm/day was always associated with miscarriage. These data suggest that criteria to diagnose miscarriage based on growth in MSD and CRL are potentially unsafe. However, finding an empty gestational sac on two scans more than 7 days apart is highly likely to indicate miscarriage, irrespective of growth.
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Affiliation(s)
- Y Abdallah
- Institute of Reproductive and Developmental Biology (IRDB), Imperial College London, Hammersmith Campus, London, UK.
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Pexsters A, Luts J, Van Schoubroeck D, Bottomley C, Van Calster B, Van Huffel S, Abdallah Y, D'Hooghe T, Lees C, Timmerman D, Bourne T. Clinical implications of intra- and interobserver reproducibility of transvaginal sonographic measurement of gestational sac and crown-rump length at 6-9 weeks' gestation. Ultrasound Obstet Gynecol 2011; 38:510-515. [PMID: 21077156 DOI: 10.1002/uog.8884] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/27/2010] [Indexed: 05/30/2023]
Abstract
OBJECTIVES To assess intra- and interobserver agreement of routinely performed measurements-crown-rump length (CRL) and mean gestational sac diameter (MSD)-for assessing the likelihood of miscarriage in the first trimester of pregnancy using transvaginal sonography. METHODS A cross-sectional study of CRL and gestational sac measurements in first-trimester pregnancies was conducted in a fetal medicine referral center with a predominantly Caucasian population. Gestational age ranged from 6 to 9 weeks. All patients underwent a transvaginal ultrasound examination using a high-resolution ultrasound machine. Two measurements of CRL and measurements of three diameters of the gestational sac were obtained by two observers. Agreement within and between observers for CRL and between observers for MSD was analyzed using 95% prediction intervals, Bland-Altman plots with 95% limits of agreement and the intraclass correlation coefficient (ICC). RESULTS In total 54 patients were included in the study, with measurements obtained by both observers in 44 of these. Intra- and interobserver ICCs were high for CRL measurements, with values of 0.992 and 0.993 for intraobserver agreement and 0.993 for interobserver agreement. For the MSD, the interobserver ICC was 0.952. Limits of agreement were ± 8.91 and ± 11.37% for intraobserver agreement of CRL and ± 14.64% for interobserver agreement of CRL. For MSD, the interobserver limits of agreement were ± 18.78%. For an MSD measurement of 20 mm by the first observer, the prediction interval for the second observer was 16.8-24.5 mm. For a CRL measurement of 6 mm, the prediction interval for the second observer was 5.4-6.7 mm. CONCLUSION For dating purposes, there is reasonable reproducibility of CRL measurements using transvaginal ultrasonography at 6-9 weeks' gestation. When diagnosing miscarriage based on measurements of CRL care must be taken for values close to any decision boundary. The higher interobserver variability that we observed for MSD has implications for the diagnosis of miscarriage based on this measurement in the absence of a visible embryo or yolk sac.
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Affiliation(s)
- A Pexsters
- Department of Obstetrics and Gynaecology, University Hospitals, Katholieke Universiteit Leuven, Leuven, Belgium.
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Wise J. Current ultrasonographic criteria for miscarriage could lead to misdiagnosis, say researchers. BMJ 2011; 343:d6665. [PMID: 22001784 DOI: 10.1136/bmj.d6665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Angiolucci M, Murru R, Melis G, Carcassi C, Mais V. Association between different morphological types and abnormal karyotypes in early pregnancy loss. Ultrasound Obstet Gynecol 2011; 37:219-225. [PMID: 20503243 DOI: 10.1002/uog.7681] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/07/2010] [Indexed: 05/29/2023]
Abstract
OBJECTIVES To identify the abnormal transvaginal ultrasound (TVS) findings typical of aneuploidic pregnancies that end with early pregnancy loss (EPL). METHODS This was a prospective clinical trial over a 2½-year period from January 2004 to June 2006 at the University Hospital of Cagliari, Italy. One hundred and fifty-six singleton pregnancies with EPL were evaluated by TVS, both before and at the moment of EPL diagnosis. Fetal karyotyping was performed on products of conception using microsatellite analysis to exclude maternal contamination in 46,XX cases. The proportions of abnormal karyotypes were compared among different groups of EPLs characterized by different morphological features. RESULTS Six morphological types were identified in EPLs, one normal and five abnormal (small gestational sac, small embryo/fetus, early symmetrical arrested growth, enlarged yolk sac and empty sac). The highest rate of chromosomal abnormalities was observed in the early symmetrical arrested growth group (100%), followed by small embryo/fetus (94.1%), enlarged yolk sac (93.3%) and empty sac (72.2%) groups. The majority of cases of trisomy 22 (92.3%) were in the enlarged yolk sac group and the majority of cases with a 45,X karyotype were in the small embryo/fetus group (77.8%). CONCLUSIONS There is an association in EPLs between some abnormal karyotypes and some morphological types. The demonstration by TVS of abnormalities in the development of early pregnancy structures could be helpful for predicting aneuploidy in EPLs.
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Affiliation(s)
- M Angiolucci
- Department of Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy
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Niinimäki M, Heikinheimo O. [Treatment of early miscarriage]. Duodecim 2011; 127:67-73. [PMID: 21442876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Bloody discharge in early pregnancy is the most common cause of gynecological out-of-hours consultation. With the ultrasound equipment becoming more common, the diagnostics of miscarriages is also increasingly possible within primary health care. Before the treatment decision, the doctor should reliably distinguish a viable pregnancy from miscarriage, and recognize the possibility of extrauterine pregnancy. Miscarriages can be treated with mechanical emptying of the uterus (curettage) or with anti-contraction medication, or the situation may be left under surveillance. The treatment is largely dictated by the type of miscarriage. Drug therapy has been found to be safe and has consolidated its position.
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Tan S, İpek A, Pektas MK, Arifoğlu M, Teber MA, Karaoğlanoğlu M. Irregular yolk sac shape: is it really associated with an increased risk of spontaneous abortion? J Ultrasound Med 2011; 30:31-36. [PMID: 21193702 DOI: 10.7863/jum.2011.30.1.31] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVES The yolk sac is the first conceptional structure that becomes sonographically visible within the gestational sac. Because the yolk sac is the primary route of exchange between the embryo and the mother, it is essential in early embryonic life. This study aimed to determine whether an irregular yolk sac shape is associated with an increased risk of spontaneous abortion. METHODS The shape and size of the yolk sac were assessed by transvaginal sonography in 183 women who had normal and healthy pregnancies with gestational ages of 6 to 8 weeks. RESULTS Most of the embryos had a yolk sac with a regular shape (152 of 183 [83%]), whereas the remaining embryos had a yolk sac with an irregular shape (31 of 183 [17%]). Although there was a trend toward a lower rate of irregular yolk sacs with advancing gestational age, the difference was not statistically significant (P = .13). Spontaneous abortion occurred in 6 of 183 pregnancies (3.3%): 1 of the 31 (3.2%) with an irregular yolk sac shape and 5 of the 152 (3.3%) with a regular yolk sac shape. The rates of spontaneous abortion were statistically similar for pregnancies with a regular yolk sac shape and those with an irregular shape (P > .99). CONCLUSIONS This study suggests that an irregular yolk sac shape is unrelated to an increased risk of spontaneous abortion.
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Affiliation(s)
- Sinan Tan
- Department of Radiology, Atatürk Education and Research Hospital, Eskişehir Yolu 8 km, 3 Bilkent, 06800 Ankara, Turkey.
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