Clinical and Ultrasound Evaluation of Early Threatened Miscarriage to Predict Pregnancy Continuation up to 28 Weeks: A Prospective Cohort Study

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.

Effect of micronized progesterone on fetal-placental volume in first-trimester threatened abortion

PURPOSE

To compare the effect of oral micronized progesterone (OMP) on the first-trimester fetal and placental volumes using three-dimensional ultrasonography and extended imaging virtual organ computer-aided analysis (XI VOCAL) method in threatened abortion.

METHODS

This randomized controlled trial enrolled women with threatened abortion and a singleton pregnancy from 6-8 6/7 weeks of gestation. A total of 60 women with threatened abortion were randomly assigned to one of two groups: OMP (400 mg/day) (n = 30) and control groups (n = 30). The XI VOCAL method was used for all volume measurements using three-dimensional ultrasonography. All patients were evaluated for fetal, amniotic, and placental volumes during the initial diagnosis and after 4 weeks.

RESULTS

After treatment, placental volume difference was significantly higher in the OMP group (336%, 67-1,077) than in the control group (141%, 29-900) (p = 0.007). The mean differences in gestational sac, amniotic sac, and embryonic volumes between the OMP and control groups were not statistically significant.

CONCLUSIONS

Hormonal support with OMP is associated with increased placental volume in first-trimester threatened abortion when compared with the control group. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:14-19, 2017.

[LEFT AND RIGHT UTERINE ARTERY DOPPLER AS EARLY SKREENING TEST OF THREATENED ABORTION OUTCOME.]

Human reproduction entails a fundamental paradox: although critical to the survival of the species, many aspects are inefficient and wastage seems excessive. Only 50-60% of all conceptions advance beyond 20 weeks of gestation. Miscarriage was defined by WHO as a loss of pregnancy before 20 weeks of gestation or weight of baby under 500 gr. Threatened abortion is the first, reversible phase of miscarriage. The pregnancy outcome doesn't always correlate to severe of its cardinal symptoms- vaginal bleeding and abdominal pain. The measure of HHG can't accurately predict the pregnancy outcome. Ultrasound scanning is probably the best single diagnosic and prognostic test in managing cases of threatened abortion. Uterine artery Dopler waveforms analysis in patients with threatened abortion is non-invasive method, which can find pathological signs in the beginning of pregnancy. Development of a molecular biology give an opportunity to find out problems of pregnancy in the process of implantation, a technical progress in ultrasound give a chance to sudy changes in uterine blood flew in early deadlines and to finding new addictions between uterine perfusion and embryo development.

Threatened miscarriage in the first trimester and retrochorial hematomas: sonographic evaluation and significance

BACKGROUND

Vaginal bleeding during the first half of pregnancy occurs in approximately 25% of women and about half of these pregnancies terminate in abortion. In many instances a retrochorial hematoma (RCH) is sonographically found.

OBJECTIVE

The aim of the present study was to determine the frequency of a RCH in the group of threatened miscarriages and to examine the possible relationship of parity, previous miscarriages, hematoma size and localization, and duration of vaginal bleeding to pregnancy outcome.

MATERIALS AND METHODS

The study group consisted of 45 women of 852 (5.2 %) referred for ultrasound examination due to vaginal bleeding in the first trimester of pregnancy, who were found to have a RCH in the presence of a singleton live embryo. The control group consisted of 807 women with the same gestational age, with vaginal bleeding, and vital singleton pregnancy without sonographically proven RCH. All were followed with repeated sonograms at seven days intervals until bleeding ceased, the RCH disappeared or abortion occurred. The authors have examined the possible relationship of duration of vaginal bleeding, hematoma size and localization, parity, and previous miscarriages to pregnancy outcome (spontaneous abortion, term or preterm delivery).

RESULTS

The researches have shown that the previous miscarriages and deliveries do not affect the occurrence of RCH. In the group with a RCH on the back wall of uterus, as well as repeated bleedings affect higher frequency of spontaneous miscarriages. Hematoma size itself does not affect higher frequency of spontaneous miscarriage.

CONCLUSION

Ultrasound is the method of choice for diagnosing the existence of aRCH. The frequency of RCH in the group of threatened spontaneous miscarriages is 5.2 %. A RCH on the back wall and repeated bleedings affect higher frequency of spontaneous miscarriages. Therapy procedure is based on strict bed rest and administration of: pregnyl, gestagenic drugs, progesterone, antihistamines, and sedatives.

Prediction of abortion using three-dimensional ultrasound volumetry of the gestational sac and the amniotic sac in threatened abortion

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.

"Empty" sac in pregnant women with bleeding: are measurements answering the right question?

PURPOSE

To assess the percentage of first-trimester pregnancies with bleeding that demonstrate a visible sac but lack an identifiable embryo and have a mean sac diameter (MSD) in the controversial range of 16-20 mm.

METHODS

Retrospective study of all first-trimester sonograms among women with vaginal bleeding during a 4-year interval.

RESULTS

The study cohort consisted of 546 first- trimester sonograms. An embryo was not seen in 132 cases (24%). Of these, the MSD in 69 cases (52%) was <16 mm, between 16 and 19 mm in 20 cases (15%), or >or=20 mm in 39 cases (30%). The percentage of women who were threatening to abort who demonstrated a visible sac but lacked an identifiable embryo and had a MSD in the controversial range of 16-20 mm was 3.7% (20/546).

CONCLUSION

We found that of 546 sonograms undertaken in pregnant women with vaginal bleeding in the first trimester, only 20 patients (3.7%) fell in the MSD range of 16-20 mm. Therefore, even among those diagnosticians who adopt the most stringent criterion (MSD = 20 mm), an additional examination would be requested in fewer than 1 in 25 patients.

[The fetus protection effects of Zhixue Baotai Decoction on women of early threatened abortion with dark area surrounding pregnancy sac]

OBJECTIVE

To observe the fetus protection effects of Zhixue Baotai Decoction (ZBD) on women of early threatened abortion with dark area surrounding pregnancy sac.

METHODS

The 105 patients with early threatened abortion, in whom vaginal bleeding was shown already, were randomly assigned to the treatment group and the control group, who were treated respectively with ZBD and progesterone to protect fetus. The efficacy of treatment was evaluated by dynamic monitoring of serum hormone and B-ultrasonic examination.

RESULTS

Among the 54 cases in the treatment group the fetus was protected successfully, showing a fetus protecting rate of 81.5%; while among the 51 cases in the control group, the protection was effective in 22 cases (43.1%), the success rate in the former was better (P<0.01). The dark area was absorbed in 16 out of 19 cases (84.2%) in the treatment group, while in the control group absorption occurred only in 6 out of 17 (35.3%).

CONCLUSION

The effect of ZBD is superior to that of progesterone in treating women of early threatened abortion with dark area surrounding pregnancy sac.

Ultrasonographic characteristics in patients clinically diagnosed with threatened abortion

OBJECTIVE

To determine ultrasonographic appearances in pregnant women clinically diagnosed with threatened abortion.

DESIGN

Cross-sectional study.

MATERIAL AND METHOD

Seven hundred and seventy six pregnant women clinically diagnosed with threatened abortion and receiving ultrasonographic examination were enrolled Data on ultrasonographic characteristics were obtained from records at the Maternal-fetal Medicine unit. Pregnancy outcomes were reviewed from medical records.

RESULTS

The ultrasonographic findings demonstrated 328 (42.3%) viable pregnancy, 178 (22.9%) embryonic death, 176 (22.7%) anembryonic pregnancy, 25 (3.2%) incomplete abortion, 24 (3.1%) complete abortion, seven (0.9%) molar pregnancy, four (0.5%) ectopic pregnancy, and 34 (4.4%) inconclusive finding. Two hundred and sixty viable pregnancies were available for follow-up and revealed that 229 (88.1%) eventually delivered while 31 (11.9%) ended up with abortion. The two groups were not significantly different regarding age, parity, history of abortion, and gestational age at diagnosis.

CONCLUSION

Ultrasonographic findings in patients clinically diagnosed with threatened abortion demonstrated viable pregnancy in nearly half of the cases. Transvaginal ultrasonography is useful in establishing definite diagnosis and appropriate treatment among these patients.

Subchorionic hemorrhage treatment with dydrogesterone

The objective of the study was to evaluate the efficacy of progestogenic therapy for the prevention of spontaneous abortions in patients with subchorionic hemorrhage. One hundred pregnant women with bleeding and ultrasonographic evidence of subchorionic hematoma were treated with oral dydrogesterone 40 mg/day. Only cases in which the embryo was viable were included. The follow-up included ultrasonography and intravaginal examination. Of the 100 pregnancies, 93 had a favorable evolution with maintenance of pregnancy. The abortion rate was therefore 7%. This compares with an abortion rate of 18.7% obtained in a previous study in women with subchorionic hematoma treated with micronized progesterone. The abortion rate was therefore reduced by up to 37% with dydrogesterone, as most cases had large-volume hematomas at the first visit and thus a poor prognosis. In conclusion, the marked immunomodulatory effect of dydrogesterone in maintaining a T helper-2 cytokine balance means that it is a good choice for preventing abortion in women suffering from subchorionic hemorrhage.

Endometrial stripe thickness and pregnancy outcome in first-trimester pregnancies with bleeding, pain or both

OBJECTIVE

To determine the association between endometrial stripe (ES) thickness and pregnancy outcome in women with a symptomatic first-trimester pregnancy and to determine how vaginal bleeding, pelvic pain and 1 human chorionic gonadotropin (hCG) level affect ES thickness.

STUDY DESIGN

Data on ES thickness, serum hCG, presence of pain, characterization of vaginal bleeding and ultimate clinical outcome were collected for 576 women presenting to the emergency room.

RESULTS

ES was thinner with increased vaginal bleeding and associated with hCG level and pregnancy outcome. The mean ES for ectopic pregnancies (EPs) was 9.56 +/- 4.87, for intrauterine pregnancies was 12.12 +/- 6.0 and for spontaneous abortion was 10.19 +/- 6.10. Ninety-nine percent of patients with EP had an ES <21 mm, and 100% had one < or =25 mm.

CONCLUSION

There was considerable overlap in ES for the 3 pregnancy outcomes, making it a poor diagnostic test. Nevertheless, ES >21 mm in a woman with no evidence of a gestational sac excludes EP with 96% specificity. A patient with a stripe >25 mm may be expectantly managed.

Uteroplacental circulation in early pregnancy complicated by threatened abortion supplemented with vaginal micronized progesterone or oral dydrogesterone

OBJECTIVE

To compare the influence of vaginal micronized progesterone and oral dydrogesterone supplementation on uteroplacental circulation in early pregnancy that is complicated by threatened abortion.

DESIGN

Randomized, parallel group, double-blind, double dummy-controlled study.

SETTING

Tertiary care university hospital.

PATIENT(S)

Fifty-three patients with threatened abortion and a living embryo.

INTERVENTION(S)

Three hundred milligrams of micronized vaginal progesterone or 30 mg of oral dydrogesterone daily supplementation for 6 weeks, serial transvaginal Doppler ultrasound measurement of pulsatility index, resistance index, and systolic/diastolic ratio of the spiral arteries, the uterine arteries, and the intrachorionic area.

MAIN OUTCOME MEASURE(S)

Uteroplacental blood flow.

RESULT(S)

The study demonstrated that vaginal progesterone administration, but not oral dydrogesterone treatment, results in the decrease in the spiral artery pulsatility and resistance index and systolic/diastolic ratio. Insignificant decrease in pulsatility index and resistance index of the uterine artery was observed at >9 weeks and was not associated with treatment regimen. Dydrogesterone treatment was only accompanied by the decrease in the uterine artery systolic/diastolic ratio.

CONCLUSION(S)

Vaginal progesterone and oral dydrogesterone supplementation have a different influence on the uteroplacental circulation in early pregnancy that is complicated by threatened abortion.

Treating threatened abortion with Chinese herbs: a case report

In the report a patient who suffered from threatened abortion was successfully cured with Chinese herbs. After treatment, vaginal bleeding stopped and the aching sensation in the loins and prolapsing sensation in the abdomen disappeared. The gestational ring changed from a crescent moon shape to a normal shape.

Ultrasound Assessment of First-Trimester Bleeding

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

II-3.

Sonographic cervical length in threatened preterm labor in a South African population

OBJECTIVE

In a previous study conducted in the UK we demonstrated that only 8% of women with threatened preterm labor deliver within 7 days. Furthermore, delivery within 7 days occurred in less than 1% of women presenting with a sonographically measured cervical length > or = 15 mm, compared to 37% in those with cervical length < 15 mm. In this study we investigate the potential value of cervical length in the prediction of outcome of threatened preterm labor in a South African population.

METHODS

We examined 63 women with singleton pregnancies presenting with regular and painful uterine contractions at 24-36 (mean, 31) weeks of gestation. Women in active labor, defined by the presence of cervical dilatation > or = 3 cm, and those with ruptured membranes were excluded. On admission to the hospital a transvaginal scan was performed to measure the cervical length. The subsequent management was determined by the attending obstetrician. The primary outcome was delivery within 7 days of presentation.

RESULTS

Delivery within 7 days of presentation occurred in 20/63 (32%) pregnancies, including 20 of the 30 (67%) cases with cervical length < 15 mm and none of the 33 cases with cervical length > or = 15 mm. Logistic regression analysis demonstrated that the only significant contributor in the prediction of delivery within 7 days was cervical length (odds ratio 0.67; 95% CI 0.54-0.85; P = 0.001) with no significant independent contribution from maternal age, gestational age, body mass index, parity, use of antibiotics, previous history of preterm delivery, cigarette smoking, contraction frequency or use of tocolytics.

CONCLUSION

In this South African population, which had a high incidence of delivery within 7 days of presentation with threatened preterm labor, sonographic measurement of cervical length is equally effective as in a lower-risk population in distinguishing between true and false labor.

Obstetric outcome after threatened miscarriage with and without a hematoma on ultrasound

OBJECTIVE

To examine the effect of threatened miscarriage on second-trimester maternal serum alpha-fetoprotein (MSAFP) levels and pregnancy outcome; and to study the significance of ultrasound evidence of an intrauterine hematoma on pregnancy outcome in these patients.

METHODS

A retrospective, case-control study was performed on 144 women presenting with bleeding in the first trimester and 144 age-matched control subjects who attended for routine dating scans during the same time scale. The presence or absence of an intrauterine hematoma, MSAFP, and pregnancy outcomes were recorded.

RESULTS

The incidence of adverse pregnancy outcome was significantly (P=.02) higher in women with a history of first-trimester threatened miscarriage than in the control group. The relative risk (RR) of an adverse pregnancy outcome for the study group was 2.22 (95% confidence interval [CI] 1.12, 4.39) compared with the control group. The RR of delivering a baby of less than 1000 g was 4.43 (95% CI 0.5, 39.2) in women with first-trimester threatened miscarriage. This was independent of the presence of an intrauterine hematoma. The RR of MSAFP being raised to more than 2.5 multiples of the median (MoM) in the study group was 6.25 (95% CI 0.77, 50.6). There was no difference between women with threatened miscarriage who had or did not have ultrasound evidence of an intrauterine hematoma.

CONCLUSION

Threatened miscarriage in the first trimester is associated with an increased incidence of adverse pregnancy outcome, independently of the presence of an intrauterine hematoma. Higher MSAFP in threatened miscarriage suggests a direct placental injury even in the absence of a hematoma.

[Aqua exercise as a prophylaxis of fetal anoxia]

The paper presents the results of the action of underwater exercises and adaptational respiratory exercise under the hypoventilation mode on health of pregnant women with threatened abortion at different terms of gestation and of their babies. The exercises led to physiological development of pregnancy, diminished intrauterine fetal hypoxia, less frequent hospitalizations of the pregnant women, good pregnancy outcomes, delivery of healthy babies. Moreover, maternal morbidity decreased 1.5-fold and perinatal morbidity 2-fold.

Pregnancy outcome of threatened abortion with subchorionic hematoma: possible benefit of bed-rest?

BACKGROUND

Bleeding in the first trimester of pregnancy is a common phenomenon, associated with early pregnancy loss. In many instances a subchorionic hematoma is found sonographically.

OBJECTIVE

To evaluate the possible benefit of bed-rest in women with threatened abortion and sonographically proven subchorionic hematoma, and to examine the possible relationship of duration of vaginal bleeding, hematoma size, and gestational age at diagnosis to pregnancy outcome.

METHODS

The study group consisted of 230 women of 2,556 (9%) referred for ultrasound examination because of vaginal bleeding in the first half of pregnancy, who were found to have a subchorionic hematoma in the presence of a singleton live embryo or fetus. All patients were advised bed-rest at home; 200 adhered to this recommendation for the duration of vaginal bleeding (group 1) and 30 continued their usual lifestyle (group 2). All were followed with repeated sonograms at 7 day intervals until bleeding ceased, the subchorionic hematoma disappeared, or abortion occurred. The groups were compared for size of hematoma, duration of bleeding, and gestational age at diagnosis in relation to pregnancy outcome (spontaneous abortion, term or preterm delivery).

RESULTS

The first bleeding episode occurred at 12.6 +/- 3.4 weeks of gestation (range 7-20 weeks) and lasted for 28.8 +/- 19.1 days (range 4-72 days). The women who adhered to bed-rest had fewer spontaneous abortions (9.9% vs. 23.3%, P = 0.006) and a higher rate of term pregnancy (89 vs. 70%, P = 0.004) than those who did not. There was no association between duration of vaginal bleeding, hematoma size, or gestational age at diagnosis of subchorionic hematoma and pregnancy outcome.

CONCLUSIONS

Fewer spontaneous abortions and a higher rate of term pregnancy were noted in the bed-rest group. However, the lack of randomization and retrospective design of the outcome data collection preclude a definite conclusion. A large prospective randomized study is required to confirm whether bed-rest has a real therapeutic effect.

Ultrasound assessment of cervical length in threatened preterm labor

OBJECTIVE

More than 70% of women presenting with threatened preterm labor do not progress to active labor and delivery. The aim of this study was to investigate the hypothesis that in women with threatened preterm labor, sonographic measurement of cervical length helps distinguish between true and false labor.

METHODS

We examined 216 women with singleton pregnancies presenting with regular and painful uterine contractions at 24-36 (mean, 32) weeks of gestation. Women in active labor, defined by the presence of cervical dilatation > or = 3 cm, and those with ruptured membranes were excluded. On admission to the hospital a transvaginal scan was performed to measure the cervical length. The subsequent management was determined by the attending obstetrician. The primary outcome was delivery within 7 days of presentation.

RESULTS

In 173 cases the cervical length was > or = 15 mm and only one of these women delivered within 7 days. In the 43 cases with cervical length < 15 mm delivery within 7 days of presentation occurred in 16 (37%) including 6/14 (42%) treated with tocolytics and 10/29 (35%) managed expectantly. Logistic regression analysis demonstrated that the only significant contributor in the prediction of delivery within 7 days was cervical length < 15 mm (odds ratio = 101, 95% CI 12-800, P < 0.0001) with no significant contribution from ethnic group, maternal age, gestational age, body mass index, parity, previous history of preterm delivery, cigarette smoking, contraction frequency or use of tocolytics.

CONCLUSIONS

In women with threatened preterm labor, sonographic measurement of cervical length helps distinguish between true and false labor.

Current issues in management of miscarriage and early pregnancy bleeding

Miscarriage is the most common complication of pregnancy. Up to 50% of all conceptions fail (Kline et al, 1989), most before the woman is aware that she is pregnant, and between 13% (Saraiya et al, 1999) and 22% (French and Bierman, 1962) of known pregnancies miscarry. Despite this frequency of incidence, miscarriage remains poorly managed and understood by many health-care professionals and women alike.

Reported management of early-pregnancy bleeding and miscarriage by general practitioners in Victoria

OBJECTIVES

To describe the management of early-pregnancy bleeding and miscarriage reported by general practitioners in Victoria.

DESIGN, SETTING, AND PARTICIPANTS

Self-administered, mailed survey of a stratified random sample of GPs in Victoria. Responses weighted by strata to reflect GP population.

MAIN OUTCOME MEASURES

Reported management in referral; investigation (especially ultrasound); expectant versus interventional management; and prevention of rhesus iso-immunisation

RESULTS

382 of 621 eligible GPs responded (response rate, 62%). GPs' reported referral was more likely if the patient had painful bleeding (55%) or if the pregnancy was not viable (77%). Ultrasound strongly influenced the assessment of bleeding. Two-thirds of doctors (262/369; 66%) would routinely order ultrasound for painless bleeding, and 328/369 (84%) for painful bleeding. Expectant management was recommended by 15/353 (4%) for incomplete miscarriage with light bleeding and by 6/351 (2%) when bleeding was heavy. Some GPs are uncertain of the indications for anti-D prophylaxis, including instrumentation of the uterus, for which 261/337 (77%) said they would routinely offer anti-D. There was less agreement about anti-D after threatened miscarriage, for which 213/353 (57%) said they offered the injection.

CONCLUSIONS

GPs need a working knowledge of the management of early-pregnancy bleeding, and can probably encourage more rational management. There are significant areas where GPs are uncertain, often reflecting uncertainty elsewhere, and some areas where a minority of GPs are not aware of essential requirements.

[Qualitative blood flow parameters in the spiral artery and progesterone concentration in pregnancy complicated by threatened abortion]

OBJECTIVES

The aim of the study was to determine the values of i.e. resistance index (RI) and pulsatility index (PI) in the spiral arteries and to evaluate the maternal serum concentration of progesterone trying to find correlation between these parameters in the group of patients in early pregnancy complicated by threatened abortion.

STUDY METHODS

We have analysed 30 pregnant women between 5th and 12th weeks of pregnancy with the symptoms of vaginal bleeding & lower abdominal pains diagnosed as threatened abortion. In all patients transvaginal ultrasound examination with pulse color Doppler was performed. The RI and PI values were calculated for blood flow velocity waveforms obtained from the spiral arteries. The concentration of progesterone in maternal serum was evaluated by Microparticle Enzyme Immunoassay. The correlation between analysed parameters and pregnancy duration was examined with use of linear correlation by Pearson. The correlation between Doppler and biochemical parameters were analysed with use of rang correlation method by Spearman.

RESULTS

Thirty flow velocity waveforms from spiral arteries were analysed and blood flow indices were calculated. We have found statistically significant negative correlation between the values of both blood flow parameters (RI & PI) and successive weeks of pregnancy (p < 0.001) and statistically significant positive correlation between maternal serum concentration of progesterone and pregnancy duration (p < 0.05). In the tested group in 40% of patients the level of progesterone was abnormal. We have not find any correlation between serum progesterone concentration and doppler parameters in our study.

CONCLUSIONS

There is observed the characteristic drop of resistance to the blood flow in the vessels of the uteroplacental circulation in the successive weeks of early pregnancy in patients with threatened abortion similar to normal early pregnancies. Lack of correlation between maternal serum concentration of progesterone and blood flow parameters indicates that other hormonal factors play major role in the regulation of the blood flow in these vessels in early pregnancy. Only the combination of Doppler blood flow analysis in spiral arteries and progesterone evaluation in the maternal serum performed in first trimester may be useful for the intensive fetal monitoring of high risk pregnancies.

Evaluation of first trimester pregnancy in cases of threatened abortion by means of doppler sonography

OBJECTIVE

Threatened abortion is one of the major problems in Obstetrics and applies to (1/3) of all pregnancies. The aim of this study was to establish normal ranges for Doppler indices of the flow velocity waveforms in uterine arteries (S/D, RI, PI) and ss-hCG serum concentrations in a control group in the first trimester of pregnancy. The obtained values were compared with those obtained in pregnancies threatened by abortion (6 - 11 weeks).

METHODS

Investigated groups: 55 controls and 47 with symptoms of threatened abortion, 27 of them aborted. Ultrasound examinations were carried out by means of an endovaginal probe. Serum ss-hCG was determined by immunoenzymatic method. The standards for measured values were established based on means from measurements obtained in the control group in the corresponding week of pregnancy.

RESULTS

We observed negative correlation between gestational age and RI and negative tendencies for S/D and PI indices in the control group. Positive correlation (p < 0.05) was found between ss-hCG serum concentration and gestational age (up to 9(th) week) and significant differences in ss-hCG concentrations between both examined groups. There were also statistical differences for S/D, RI and PI indices in both analyzed groups for each week of pregnancy.

CONCLUSION

We conclude that measurement of the quality parameters of the flow velocity waveforms in uterine arteries and calculation of beta-hCG concentration in serum are useful methods in diagnosis of threatened abortion in the first trimester of pregnancy.

Sonographic findings in clinically diagnosed threatened abortion

OBJECTIVE

To determine the sonographic appearances in pregnant women who presented with vaginal bleeding in the first 20 weeks of gestation.

METHOD

Pregnant women of under 20 gestational weeks diagnosed clinically as threatened abortion were recruited for ultrasound scan at the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University. The sonographic findings were reported as viable pregnancy, anembryonic pregnancy, embryonic death, incomplete abortion, complete abortion, ectopic pregnancy, molar pregnancy and inconclusive findings. Patients with inconclusive findings were followed weekly until final diagnoses were established. All patients were followed-up to 20 weeks or until the final outcomes were revealed.

RESULTS

Two hundred and sixty eight pregnant patients were enrolled. Ultrasound scans demonstrated 100 viable fetuses (37.3%), 73 embryonic deaths (27.3%), 46 anembryonic pregnancies (17.2%), 6 molar pregnancies (2.2%), 3 ectopic pregnancies (1.1%), 14 complete abortions (5.2%) and 26 inconclusive findings (9.7%). Follow-up scan on patients with inconclusive findings revealed 9 anembryonic pregnancies (3.3%), 9 incomplete abortions (3.3%), 1 embryonic death (0.4%) and 1 viable pregnancy (0.4%). Six patients (2.3%) were lost to follow-up. The viable pregnancy rate according to maternal age was highest at the maternal age of 25 to 29 years old (49%), whereas, it was lowest at the maternal age of 40 to 44 years old (0%). The viable pregnancy rate according to gestational age was highest at 6 to 8 weeks (61.2%), whereas, it was lowest at 18 to 20 weeks (20%).

CONCLUSION

Sonographic findings in patients with clinically diagnosed threatened abortion demonstrated viable pregnancies in around one-third of the cases. Use of ultrasound in clinically diagnosed threatened abortion may assist clinicians in establishing a definite diagnosis so that appropriate care could be offered to the patients.

Do patients matter? Contribution of patient and care provider characteristics to the adherence of general practitioners and midwives to the Dutch national guidelines on imminent miscarriage

OBJECTIVE

To assess the relative contribution of patient and care provider characteristics to the adherence of general practitioners (GPs) and midwives to two specific recommendations in the Dutch national guidelines on imminent miscarriage. The study focused on performing physical examinations at the first contact and making a follow up appointment after 10 days because these are essential recommendations and there was much variation in adherence between different groups of providers.

DESIGN

Prospective recording by GPs and midwives of care provided for patients with symptoms of imminent miscarriage.

SETTING

General practices and midwifery practices in the Netherlands.

SUBJECTS

73 GPs and 38 midwives who agreed to adhere to the guidelines; 391 patients were recorded during a period of 12 months.

MAIN MEASURES

Adherence to physical examinations and making a follow up appointment were measured as part of a larger prospective recording study on adherence to the guidelines on imminent miscarriage. Patient and care provider characteristics were obtained from case recordings and interviews, respectively. Multilevel analysis was performed to assess the contribution of several care provider and patient characteristics to adherence to two selected recommendations: the number of recommended physical examinations at the first contact and the number of days before a follow up appointment took place.

RESULTS

In the multilevel model explaining variance in adherence to physical examinations, the care provider's acceptance of the recommendations was the most important factor. Severity of symptoms and referral to an obstetrician were significant factors at the patient level. In the model for follow up appointments the characteristics of the care provider were less important. Referral to an obstetrician and probability diagnosis were significant factors at the patient level.

CONCLUSIONS

The study showed that characteristics of both the patient and care provider contribute to the variability in adherence. Furthermore, the contribution of the characteristics differed per recommendation. It is therefore advised that the contribution of both patient and care provider characteristics per recommendation should be carefully examined. If implementation is to be successful, strategies should be developed to address these specific contributions.

The Sonography of Pregnancy Loss

Sonography is critical to the current management of pregnancy loss. It is used to predict and/or confirm viability. Knowledge of the early embryology as well as the timing of these events is important to appropriate management. Sonographic parameters can be divided into hard and soft signs. Hard signs include the absence of visible heart motion or embryonic poles at certain cutoffs. The soft signs are generally related to findings more likely to be associated with poor outcomes. Ultrasound is now also used to help determine which patients may not require surgical intervention.

Expectant management versus elective curettage for the treatment of spontaneous abortion

OBJECTIVE

To determine whether the amount of intrauterine tissue was prognostic of the risk of complications associated with the management of nonviable pregnancies diagnosed in the first trimester before cervical dilatation (termed here impending abortion) with either expectant observation or elective curettage.

DESIGN

Historic cohort study.

SETTING

University Infertility Service.

PATIENT(S)

All women with nonviable pregnancies followed by the Division of Reproductive Endocrinology during a 5-year period. The patients were divided into those with significant intrauterine tissue (gestational sac > 10 mm) and those with minimal intrauterine tissue.

INTERVENTION(S)

Women either underwent elective curettage or were followed expectantly.

MAIN OUTCOME MEASURE(S)

Complication rates.

RESULT(S)

In 89 women with minimal tissue, no complications occurred regardless of treatment mode. In 63 women with significant intrauterine tissue, expectant management resulted in more complications (9/24) than elective curettage (1/39). In the expectant group, complications included missed abortion, septic abortion, and incomplete abortion requiring emergency curettage, with one patient requiring a transfusion. In the curettage group one uterine perforation occurred.

CONCLUSION(S)

In women with impending abortions and minimal intrauterine tissue, expectant treatment is safe after ectopic pregnancy has been excluded. In patients with significant intrauterine tissue, the risk of complications may be decreased by elective uterine curettage compared with expectant management.

The management of first trimester miscarriage by general practitioners in Ireland

A single shot questionnaire was sent to 500 general practitioners, with 39 per cent valid response, to audit first trimester miscarriage management. With threatened miscarriage 60 per cent were cared for at home (10 per cent of these had ultrasound) and 40 per cent were transferred to hospital. The miscarriage rate was 14 per cent-61.7 per cent had no symptoms (of these 42.2 per cent had a positive pregnancy test), 24.4 per cent had threatened miscarriage with 11.6 per cent incomplete and 2.3 per cent complete. The general practitioner is ideally placed to develop initial clinical management strategies and direct access to ultrasound would be helpful.

The spectrum of first-trimester ultrasound findings

A wide spectrum of sonographic findings can be seen in the first trimester of pregnancy. One must have an appreciation of embryology to recognize normal and abnormal early pregnancy development. In this article we emphasize discriminatory criteria for identification of normal structures, as well as ultrasound findings in threatened abortion, failing pregnancy, multiple gestations, ectopic pregnancy, and trophoblastic disease. Sonoembryology, the identification of embryonic anatomy, is discussed, as are examples of early identification of anomalies.

Women with bleeding in the first 20 weeks of pregnancy: value of general practice ultrasound in detecting fetal heart movement

BACKGROUND

Real-time ultrasound scanning has made it possible to ascertain whether the fetus is alive in women who have bleeding in early pregnancy. Portable ultrasound machines are capable of detecting fetal heart movement reliably after the ninth week of pregnancy, and can be used in a general practice setting. An ultrasound clinic was set up in a health centre and 22 general practitioners in the local area could refer women patients with bleeding in early pregnancy.

AIM

A study was carried out among women with bleeding in early pregnancy to compare the presence of fetal heart movement detected at the initial ultrasound scan with subsequent fetal survival during the first 20 weeks of pregnancy.

METHOD

Data were collected during a three-year period on women referred opportunistically by their general practitioners. An abdominal scan was performed on the same day or the day after presentation and the presence or absence of fetal heart movement recorded. Diagnoses and outcome at 20 weeks were ascertained from patients' health centre records.

RESULTS

A total of 240 women with bleeding in early pregnancy were scanned and at the first examination fetal heart movement was detected in 115 of the fetuses (48%). Three fetuses were subsequently miscarried spontaneously while 109 of the 115 continued to the 20th week (95%). Three fetuses had gross abnormalities and these pregnancies were subsequently terminated. No heart movement was detected in 117 fetuses (49%); all were subsequently miscarried. For eight women scanned it was not clear whether fetal heart movement was present. Three of these eight pregnancies survived to the 20th week. Predictive values of fetal survival to the 20th week of pregnancy from fetal heart movement detected by general practice ultrasound scan for women with bleeding in early pregnancy showed a sensitivity of 97% and a specificity of 98%.

CONCLUSION

If fetal heart movement is detected at the initial scan, approximately 19 out of every 20 viable pregnancies (those in which the fetus appears normal) will not miscarry before the 20th week. Using ultrasound in general practice it was possible to identify promptly those women with bleeding whose fetus was alive. For those women found to have a non-viable pregnancy, appropriate arrangements could be made at an early stage in the knowledge that a miscarriage was inevitable, thus avoiding unnecessary bed rest for the patient. Where fetal heart movement was detected, there was a good prognosis and thus women could be given strong reassurance.

[Hydatidiform mole in Vietnam. The contribution of ultrasonography]

One-hundred-and-four cases of histopathologically confirmed hydatiform moles were subjected to ultrasound examination at the Hung Vuong Hospital, Ho-Chi-Minh-ville (Vietnam) over a period of 16 months (1988-1989). The diagnosis was confirmed only in some cases on clinical grounds (18%) or by laboratory tests (52%). In contrast, typical ultrasound signs were found in 82% of cases; in the other 18% of cases, other aspects had suggested disorders calling for aspiration (partial mole, clear ovum, pregnancy terminated). Some ultrasound images, highly suggestive of mole, were found in occasional cases of mucoid ovarian cyst, endometrial cancer or cystic necrobiosis of fibroma (HCG tests negative). Despite its limitations in Vietnam ultrasound constitutes the primary method of detecting hydatiform mole, the acquisition of practical experience is facilitated by the high number of cases and the concentration of cases reported.

[Transvaginal Doppler ultrasound in early pregnancy--normal values and comparison with a risk sample with threatened abortion]

In the study introduced here, norm values for embryo-feto-placental circulation are illustrated. The values were gained by examining 75 singleton pregnancies of uncomplicated course and ending with non-problematic birth of an eutrophic child. In addition to qualitative parameters such as A/B-ratio and Pulsatility Index, the maximum systolic frequency shift was measured by transvaginal Doppler sonography between the fifth and 24th week of gestation (post menstruation), to obtain another quantitative parameter. The increasing circulation can be impressively visualized by viewing the corresponding norm value curves. This is valid for both the embryo-fetal as well as maternal side of the placenta. Over the same time period, 53 high-risk pregnancies with symptoms of premature labor were followed to enable comparison with the circulatory changes in normal pregnancy. It was not possible to differentiate normal and abnormal pregnancy regarding premature labor by examining the utero-feto-placental unit with transvaginal Doppler sonography. In direct comparison, the Doppler values showed no significant differences. The norm curves introduced in this study should be considered as a basis to evaluate the utero-feto-placental circulatory system using Doppler sonography and be of use to differentiate abnormal changes of perfusion during the course of pregnancy, soby making it possible to recognize a pregnancy at risk early on.

Assessment of the fetomaternal circulation in threatened abortion by transvaginal color Doppler

Transvaginal color Doppler was used to investigate blood flow in the fetomaternal circulation of 60 women with threatened abortion and 90 women with normal intrauterine pregnancy. The obtained Doppler sonograms were analyzed and the resistance index (RI) was calculated in the maternal circulation, while in the fetal circulation the pulsatility index (PI) was used. There was no significant difference in the RI values of the maternal circulation between women with normal pregnancies and pregnancies complicated by bleeding, but with normal pregnancy outcome (p > 0.05). No differences in RI values of the uterine, arcuate and radial arteries were found between pregnancies with threatened abortion and normal pregnancy outcome and women with abnormal outcome (p > 0.05). In 9 of 21 women with visible retrochorionic hematoma, the RI of the spiral arteries was higher on the hematoma side in comparison to the opposite side (p < 0.01). This could be a consequence of the mechanical compression caused by the hematoma. In 3 of 4 cases of missed abortion, the RI of the spiral arteries was lower in comparison to the control group. Such findings could be caused by the vasodilatating products of inflammation which probably exist in such areas. There was no significant difference in terms of the PI of fetal blood vessels between normal pregnancy and threatened abortions with normal outcome, as well as between threatened abortions with normal outcome and subsequent abortions of live fetuses (p > 0.05).

Transvaginal ultrasound in threatened abortions with empty gestational sacs

OBJECTIVE

To determine whether transvaginal ultrasound criteria alone can distinguish viable from non-viable gestational sacs at a single examination.

METHOD

A prospective descriptive study was undertaken and analysis performed on 211 pregnancies complicated by threatened abortion and empty gestation sacs diagnosed by transvaginal ultrasound. The main outcome measure was the final diagnosis of viable or non-viable gestation on subsequent transvaginal sonography.

RESULTS

The study shows that a single transvaginal ultrasound examination is useful in differentiating viable from non-viable gestation sacs. The mean sac diameter (MSD) was found to be the most useful criterion for determining non-viability. An MSD of > or = 17 mm that lacked an embryo and an MSD of > or = 13 mm without visible yolk sac were reliable predictors of non-viable gestation sacs at a single examination with 100% specificity and 100% positive predictive value. An MSD > or = 13 mm without visible yolk sac was the most sensitive criterion. Using MSD criteria, 73% of non-viable gestations could be reliably identified without any false-positive diagnoses. Deformed shape, low position and thin decidual reaction are strong indicators of non-viable gestations but are not 100% accurate. There is still a significant proportion of empty sacs, where no accurate distinction between viable and non-viable can be made according to one criterion at a single examination and in these cases serial examinations should be carried out before any active management is advocated.

CONCLUSION

In most cases, transvaginal sonographic criteria alone can distinguish viable from non-viable empty gestational sacs at a single examination.

Transvaginal color and pulsed Doppler study of uterine blood flow in the first and early second trimesters of pregnancy: normal versus abnormal

Transvaginal color Doppler ultrasonography was used to study 131 normal early pregnancies, 30 molar pregnancies, 20 threatened abortions, two blighted ova, and five pregnancies with intramural myoma. Four separate parts of the maternal circulation were studied: uterine, arcuate, radial, and spiral arteries. There was statistical difference in the RI and PI among uterine, arcuate, radial, and spiral arteries (P < 0.001) in all observed groups of patients except those with intramural myoma. When the same part of the maternal circulation was compared among different groups of patients, the following results reached statistical significance: uterine artery in normal and molar pregnancy (P < 0.001); arcuate artery in normal and molar pregnancy (P < 0.001); radial artery in normal and molar pregnancy (P < 0.001) and in normal pregnancy and threatened abortion (P < 0.01); spiral artery in normal and molar pregnancy (P < 0.001), in normal pregnancy and threatened abortion (P < 0.01), and in molar pregnancy and threatened abortion (P < 0.01). The standard values of blood flow are different in normal and in some cases of abnormal early pregnancy (molar pregnancy, threatened abortion).

An audit of general practitioner requests for pelvic ultrasound: analysis of referral patterns and outcome

OBJECTIVES

1. To assess the information supplied by general practitioners on the gynaecological ultrasound request form and to determine how this information influences the interpretation of scans; and 2. To examine the influence of scans on the subsequent management of patients both by general practitioners and, where relevant, by hospital gynaecologists.

DESIGN

Retrospective analysis of gynaecological ultrasound requests made by general practitioners. Postal questionnaire and assessment of outcome according to general practitioners' records and, where appropriate, the hospital notes.

SETTING

A London teaching hospital gynaecological ultrasound department and associated general practices.

SUBJECTS

Four hundred ninety-eight women referred by general practitioners for a gynaecological ultrasound scan over a one year period (1990).

RESULTS

The 498 requests for gynaecological ultrasound scans included 472 primary diagnostic referrals. Seventy-one percent of general practitioners replied to the questionnaires. Overall, 46% of the scans were normal, but the proportion of normal scans fell to 21% if the date of the last menstrual period and a pregnancy test result were included on the form. Forty per cent of women scanned subsequently were referred for hospital care.

CONCLUSIONS

General practitioners would appear to use the ultrasound service in a rational way and therefore there can be no justification for not allowing them open access. The positive diagnostic yield can be further improved if time is taken to supply simple relevant information which may be facilitated by a specific request form.

Evaluation of threatened preterm delivery by transvaginal ultrasonographic measurement of cervical length

OBJECTIVE

To establish a nomogram for the length of the uterocervical canal and to determine whether this can be used to predict preterm delivery.

METHODS

Cervical length was measured by transvaginal ultrasonography in 32 women (21 primigravid, 11 multigravid) with threatened preterm delivery, and in 177 normal singleton pregnancies between 18-37 weeks' gestation. Regression analysis was used to create the nomogram. Student t test was used to compare the groups.

RESULTS

A linear relationship was found between cervical length and gestational age (r = -0.4, P < .001). Comparison of cervical length on admission in the patients with threatened preterm delivery showed that 11 preterm deliveries occurred in women who had a mean cervical length of 23.2 mm (range 17-29), whereas 21 term deliveries occurred in women with a mean cervical length of 31.7 mm (range 21-42). The difference was significant (P < .001). A cervical length of less than 20 mm on admission had a positive predictive value of 100%. These patients had preterm delivery despite tocolytic therapy during hospitalization.

CONCLUSION

The risk of preterm delivery is high in women whose cervical length on admission is less than 30 mm, and strict management is required for those with a cervical length of less than 20 mm.

The prognostic significance of maternal serum CA125 measurement in threatened abortion

The prognostic predictive value of maternal serum CA125 measurement was investigated in 25 cases of threatened abortion. The women were non-smoker, had a ultrasonographically verified viable single fetus, and the gestational ages ranged from 7 to 12 weeks. Twenty-five healty pregnant women, with the same characteristics were used as the control group. The overall abortion rate was found to be 20% (5/25) in the study group. In serial measurements the mean serum CA125 level of the patients with an unfavorable pregnancy outcome was significantly higher than that of the patients with a favorable outcome. When the cut-off level of maternal serum CA125 was taken as > 65 U/ml in the first and > 60 U/ml in the second measurements of the study group, the risk of termination of the pregnancy by spontaneous abortion was 83.3% in the patients with elevated serum CA125 levels. No statistically significant difference was observed with respect to the duration of vaginal bleeding between the aborters and the patients with a favorable outcome. Nevertheless, when vaginal bleeding had been present for 3 days or more and there was high maternal serum CA125 activity, the abortion risk was found to be 100% (3/3). These findings suggest that the maternal serum CA125 measurement in threatened abortion can be useful to determine the extent of decidual destruction which is directly related to the outcome of pregnancy.

Ruptured interstitial pregnancy presenting as an intrauterine pregnancy by ultrasound

Interstitial pregnancy is an uncommon subset of ectopic pregnancy in which the conceptum implants in the intrauterine portion of the fallopian tube. These pregnancies tend to progress further before rupture than do other tubal pregnancies and subsequently have greater propensity for massive intra-abdominal bleeding and maternal demise. Abdominal ultrasound can be deceptive in evaluating interstitial ectopic pregnancies. Transvaginal ultrasonography is more sensitive in the diagnosis of early ectopic pregnancy. Knowledge of the application and limitations of both transabdominal and transvaginal ultrasound will assist the emergency physician in the timely evaluation of this potentially lethal condition.

[Changes in the fetoplacental system in threatened abortion]

Comprehensive assessment of the hormonal status of the fetoplacental system in 110 pregnant women, carried out over the course of treatment for threatened abortion, included radioimmunoassays of blood serum estriol, progesterone, and placental lactogen, cardiotocography of the fetus, ultrasonic fetometry and placentography. Trophic, hormonal, and hypoxic disorders of the fetoplacental system were revealed. The therapy resulted in essential improvement of the trophic and hypoxic conditions, though the hormonal function did not normalize as a rule.