ABSTRACT
BACKGROUND AND OBJECTIVE: It aimed to develop an expert consensus regarding the risk assessment, diagnosis, and threatened miscarriage management during the first trimester in Pakistan. METHODS: A three-step modified Delphi method was applied to develop the consensus. Eleven specialized obstetricians and gynecologists participated in its development. If 75% or higher agreement level was attained on each assertion, it was declared as a consensus. RESULTS: Age of 35 or above, previous history of two or more previous miscarriages, and direct strong trauma were considered to be threatened miscarriage risk factors. Infection was discussed and specified to include specific infectious diseases, like malaria, and COVID-19 as a risk factor. The experts agreed from the first time on considering endocrinological disorders, thrombophilia, and lifestyle variables as threatened miscarriage risk factors. They proposed adding a statement concerning acquired thrombophilia which was accepted unanimously. Finally, experts agreed on the importance of educating pregnant women about factors whose risk can be modified by modifying their behavior. As for diagnosis statements, it was agreed to be trifold: physical examination, imaging, and laboratory testing. Physical examination included abdominal and pelvic exams but focused more on vaginal examination with speculum to identify bleeding severity and etiology. The statements regarding the imaging approaches to diagnose threatened miscarriage in the first trimester achieved a consensus in most statements. TVS was recommended to check on uterine structural abnormalities, fetus viability focusing on heartbeat and crown-to-rump length, gestation sac size and emptiness, subchorionic hematoma, and ectopic pregnancy. Each was defined on how to identify and diagnose in separate statements. Statements about laboratory tests indicated the need for human chorionic gonadotropin hormone assessment whether serial or once is dependent on the ultrasound. Recommended hematologic investigations include complete blood count for anemia, Rh factor for potential bleeding risk and in special cases, thrombophilia assessment is undertaken. The first and foremost management aspect was follow-up while most management statements were controversial, and some were altogether removed with only some reaching agreement after discussion. CONCLUSION: These consensus statements aggregated the best available evidence and experts' opinion-supported statements to improve patient education, risk assessment, diagnosis, and evaluation as well as management of threatened miscarriage during the first trimester in Pakistan.
ABSTRACT
Introduction Subclinical hypothyroidism (SCH) during early pregnancy is associated with an increased risk of miscarriage or premature birth. In Pakistan, the prevalence of SCH among pregnant women is not well documented. This multi-center study aims at identifying the prevalence of SCH among Pakistani pregnant women. Methods A cross-sectional multi-center study was conducted over a period of 12 months. Pregnant females in the first trimester of pregnancy were recruited from the antenatal clinics of seven centers from six Pakistani cities. We assessed the frequency of SCH in pregnant females and associated risk factors. Results A total of 500 pregnant women were enrolled in this study. Only eight women (1.6%) had a newly-diagnosed SCH. While 1.2% of women had hyperthyroidism, 6% had known hypothyroidism, and 1% had overt hypothyroidism. Ten females (33.3%) with known hypothyroidism were receiving an inadequate dose of thyroid replacement therapy. The association between BMI and SCH was not statistically significant (p = 0.69). Moreover, we could not find any significant difference between patients with or without SCH in terms of age (p > 0.90), dyslipidemia (p = 0.157), history of miscarriage (p > 0.90), the regularity of the cycle (p > 0.90), and history of infertility (p > 0.90). Conclusions The frequency of undiagnosed SCH in pregnant females in the study from Pakistan was 1.6%. The rate of uncontrolled hypothyroidism was high, which raises an alarm of the potential risks of untreated thyroid disorder.