Serum progesterone levels could predict diagnosis, completion and complications of miscarriage.

BACKGROUND: Low serum progesterone levels were strongly correlated with miscarriages in several publications and with completion of miscarriage in one paper. This study evaluated several parameters, predominantly serum progesterone, as predictors for miscarriages, their swift non-surgical completion and their complications. BASIC PROCEDURES: Suspected or confirmed non-viable pregnancies with available concomitant serum progesterone measurements were retrospectively reviewed. The performance of serum progesterone, either alone or combined with other parameters, to predict viability, surgical removal and delay of non-surgical evacuation of non-viable pregnancy and complications, was analysed by logistic regression combined with Akaike and Bayesian information criteria, likelihood, receiver operated characteristic (ROC) curves, Mann-Whitney test and Fisher's exact test. MAIN FINDINGS: From 151 included pregnancies, 104 (68.9 %) were non-viable with 91 completions of miscarriage without surgery. The probability of viability was correlated linearly and curvilinearly with serum progesterone (p < 0.001). The probability of surgical removal, and the delay before non-surgical evacuation, showed a linear relationship with progesterone. No complication occurred when progesterone levels remained below 10 µg/L, while its rates were 9.5 % of non-viable pregnancies with progesterone levels between 10 and 20 µg/L and 26.7 % of cases with progesterone levels above 20 µg/L. Combined with progesterone, either "parity" or "history of miscarriage" improved the prediction of viability, "history of supra-isthmic uterine surgery" improved the prediction of surgery and "history of miscarriage" improved the prediction of delayed non-surgical evacuations. CONCLUSION: Serum progesterone can probably predict the odds of miscarriages, surgical removal, delayed non-surgical evacuation and complications, with potential improvements when different predictors are combined.

Same-day confirmation of intrauterine pregnancy failure in women with first- and early second-trimester bleeding.

OBJECTIVE: To determine if alpha-fetoprotein (AFP) concentration in vaginal blood, in the setting of dissolved fetal tissue, is significantly higher than its concentration in the maternal serum. DESIGN: A prospective cohort study. SETTING: Medical center. PATIENT(S): Four groups of women were evaluated: 1) with missed/incomplete miscarriage with vaginal bleeding; 2) with threatened miscarriage; 3) with vaginal bleeding during cerclage placement; and 4) undergoing dilation and curettage (D&C). INTERVENTIONS(S): None. MAIN OUTCOME MEASURE(S): In each patient, AFP concentration in the vaginal blood or in the liquid component of the evacuated products of conception (POC; D&C group) was compared with the AFP concentration in the maternal serum. RESULT(S): The median (range) concentration ratios of AFP in vaginal blood (or POC) to AFP in maternal serum were 24.5 (5.1-8,620) and 957 (4.6-24,216) for the missed/incomplete (n = 30) and the D&C (n = 22) groups, respectively, whereas they were only 1.2 (0.4-13.4) and 1.01 (0.7-1.5) for the threatened miscarriage (n = 15) and cerclage (n = 9) groups, respectively. Receiver operating characteristic (ROC) analysis demonstrated 100% sensitivity and 86.7% specificity for the detection of the passage of fetal tissue (ratio 4.3, area under the ROC curve 0.96). CONCLUSION(S): Higher concentrations of AFP in vaginal blood than in maternal serum may indicate the presence of dissolved fetal tissue (i.e., confirming a failed pregnancy).

Serum biomarkers may help predict successful misoprostol management of early pregnancy failure.

In order to simplify management of early pregnancy loss, our goal was to elucidate predictors of successful medical management of miscarriage with a single dose of misoprostol. In this secondary analysis of data from a multicenter randomized controlled trial, candidate biomarkers were compared between 49 women with missed abortion who succeeded in passing their pregnancy with a single dose of misoprostol and 46 women who did not pass their pregnancy with a misoprostol single dose. We computed the precision of trophoblastic protein and hormone concentrations to discriminate between women who succeed or fail single dose misoprostol management. We also included demographic factors in our analyses. We found overlap in the concentrations of the individual markers between women who succeeded and failed single-dose misoprostol. However, hCG levels ≥ 4000 mIU/mL and ADAM-12 levels ≥ 2500 pg/mL were independently associated with complete uterine expulsion after one dose of misoprostol in our population. A multivariable logistic model for success included non-Hispanic ethnicity and parity <2 in addition to hCG ≥ 4000 mIU/mL and ADAM-12 ≥ 2500 pg/mL and had an area under the receiver operating characteristic (ROC) of 0.81 (95% confidence interval: 72-90%). Categorizing women with a predicted probability of ≥ 0.65 resulted in a sensitivity of 75.0%, specificity 77.1% and positive predictive value of 81.8%. While preliminary, our data suggest that serum biomarkers, especially when combined with demographic characteristics, may be helpful in guiding patient decision-making regarding the management of early pregnancy failure (EPF). Further study is warranted.

[Effect of Taohong Siwu decoction on angiogenesis of medicine-induced incomplete-abortion in early pregnancy rats and expressions of Ang-1, Ang-2 and Tie-2].

OBJECTIVE: To observe the effect of Taohong Siwu decoction (THSWD) on micro-vascular density (MVD) in rat uterus, the content of angiopoietin-1 (Ang-1) and angiopoietin-2 (Ang-2) in serum, and the expression of tyrosine kinasa receptor (Tie-2) in uterus. METHOD: Early pregnancy rats were intragastrically administrated with misoprostol (100 microg x kg(-1)) and mifepristong (8.3 mg x kg(-1)) to established the incomplete-abortion model. The incomplete-abortion rats were randomly divided into the model group (the same volume of distilled water), the positive control group (at the daily dose of 4.3 g x kg(-1) Motherwort Particles), and THSWD-treated groups (at the daily dose of 18.0, 9.0 and 4.5 g x kg(-1)). Pregnant rats were taken as the control group (the same volume of distilled water). After the successive oral administration for 7 days, blood was collected from aorta abdominalis, and rat uterine tissues were collected. The content of serum Ang-1 and Ang-2 were detected by ELISA; And the levels of Tie-2 and MVD in uterine tissues were detected by SP immunohistochemistry. RESULT: THSWD remarkably increased the levels of MVD in uterus of medicine-induced abortion rats, the content of Ang-1 and Ang-2 in serum, and the expression of Tie-2 in uterine tissues. CONCLUSION: THSWD has the effect in markedly promoting angiogenesis in incomplete-abortion rats. Its mechanism may be related to the regulation of concentrations of Ang-1 and Ang-2 in serum and Tie-2 in uterine tissues.

Effects of leonurine hydrochloride on medically induced incomplete abortion in early pregnancy rats.

OBJECTIVES: To determine the effect of leonurine hydrochloride (LH) on abnormal bleeding induced by medical abortion. STUDY DESIGN: Rats had incomplete abortions induced in early pregnancy using mifepristone in combination with misoprostol. After abortion, rats were treated with LH for 7 days, and the duration and volume of uterine bleeding were observed. Approximately 30min after the last treatment, the animals were killed and the uterine shape was observed. The sinistro-uteri were suspended in organ baths to record the contraction curves, including the frequency and tension for 10min; the dextro-uteri were fixed with formaldehyde for pathologic evaluation. In addition, blood samples were collected from the femoral artery for the measurement of estradiol (E2) and progesterone (P) levels by radioimmunoassay. RESULTS: In in vivo experiments, compared with the model group, LH treatment markedly reduced the volume of bleeding and intrauterine residual, and significantly shortened the duration of bleeding. From the contraction curve, LH notably reinforced the frequency and tension of uterine contractions. LH remarkably elevated the serum estradiol level in rats, but had no obvious effect on progesterone level. CONCLUSIONS: LH has an inhibitory effect on bleeding caused by incomplete abortion; the mechanism may be related to up-regulation of the E2 level, leading to an increase in uterine contractions and evacuation of intrauterine residuum.

[Comparative study of manual vacuum aspiration and uterine curettage for treatment of abortion]. / Tratamento do abortamento incompleto por aspiração manual ou curetagem.

OBJECTIVES: To compare manual vacuum aspiration (MVA) and uterine curettage (D and C) for first trimester abortions, in terms of the efficiency of eliminating ovular remnants, frequency of complications, duration of the procedure, and duration of patients' hospitalization. METHODS: In a prospective study, 50 patients in the MVA group and 50 in the D&C group were randomly included. Inclusion criteria were: spontaneous abortion, gestational age less than 13 weeks, patent cervix, endometrial thickness >15 mm, afebrile state, and hemoglobin >10 g/dl. Blood samples were collected before and after surgical procedures for control of hemoglobin levels. Anesthesia was performed in all cases. The time required for each surgical procedure was recorded. RESULTS: Groups were similar regarding gestational age (9.93 +/- 2.40 vs 9.73 +/- 2.58 weeks; p = 0.71) and endometrial thickness before surgery (22.14 +/- 4.80 vs 22.68 +/- 5.68 mm; p = 0.65). There were no surgical or anesthetic complications in either group. Durations of the procedure and of hospitalization were significantly shorter in the MVA group (3.71 vs 10.18 min, p < 0.001, and 14.18 vs 23.06 h, p = 0.03, respectively). Decrease of hemoglobin levels was greater after the surgical procedure in the D and C group (p = 0.02). CONCLUSION: MVA caused less blood loss, was less time consuming, and resulted in shorter hospitalization. However, both surgical procedures were found to be efficient for treatment of incomplete abortions during the first trimester of pregnancy, with no complications after both treatments.

Tratamento do abortamento incompleto por aspiração manual ou curetagem / Comparative study of manual vacuum aspiration and uterine curettage for treatment of abortion

OBJETIVOS: Comparar aspiração manual intra-uterina (AMIU) com curetagem uterina (D&C) em abortamentos no primeiro trimestre no que se refere a eficiência para eliminar restos ovulares do método de aspiração manual intra-uterina com a dilatação e curetagem, ocorrência de complicações (perfuração uterina, laceração cervical, hemorragia pós-tratamento), tempo duração dos procedimentos e tempo de internação das pacientes. MÉTODOS: Cinqüenta pacientes no grupo AMIU e 50 pacientes no grupo D&C foram incluídas prospectivamente de maneira aleatória. Critérios de inclusão: abortamento espontâneo, idade gestacional de até 13 semanas, colo pérvio, espessura endometrial maior que 15 mm, estado afebril, hemoglobina superior a 10 g/dl. Amostras sangüíneas foram colhidas antes e após os procedimentos cirúrgicos para controle dos níveis de hemoglobina; anestesia foi realizada em todos os casos. O tempo para realização de cada procedimento cirúrgico foi cronometrado. RESULTADOS: Os grupos eram semelhantes quanto à idade gestacional (9,93±2,40; 9,73±2,58, p 0,71), espessura endometrial antes da cirurgia (22,14±4,80; 22,68±5,68, p 0,65). Não foram observadas complicações cirúrgicas ou anestésicas em nenhum grupo. Os tempos de realização do procedimento e internação foram significativamente menores nas pacientes do grupo AMIU (3,71; 10,18 min, p < 0,001) (14,18; 23,06 h, p 0,03). O decréscimo nos níveis de hemoglobina após o procedimento cirúrgico foi maior no grupo D&C (p= 0,02). CONCLUSÃO: A AMIU possibilita menor perda sangüínea, requer menor tempo de realização do procedimento e menor tempo de internação hospitalar. Entretanto, ambos os procedimentos cirúrgicos mostraram-se eficientes para o tratamento de abortamentos incompletos no primeiro trimestre da gestação, não havendo complicações após a realização dos tratamentos.

OBJECTIVES: To compare manual vacuum aspiration (MVA) and uterine curettage (D&C) for first trimester abortions, in terms of the efficiency of eliminating ovular remnants, frequency of complications, duration of the procedure, and duration of patients' hospitalization. METHODS: In a prospective study, 50 patients in the MVA group and 50 in the D&C group were randomly included. Inclusion criteria were: spontaneous abortion, gestational age less than 13 weeks, patent cervix, endometrial thickness >15 mm, afebrile state, and hemoglobin >10 g/dl. Blood samples were collected before and after surgical procedures for control of hemoglobin levels. Anesthesia was performed in all cases. The time required for each surgical procedure was recorded. RESULTS: Groups were similar regarding gestational age (9.93 ± 2.40 vs 9.73 ± 2.58 weeks; p = 0.71) and endometrial thickness before surgery (22.14 ± 4.80 vs 22.68 ± 5.68 mm; p = 0.65). There were no surgical or anesthetic complications in either group. Durations of the procedure and of hospitalization were significantly shorter in the MVA group (3.71 vs 10.18 min, p < 0.001, and 14.18 vs 23.06 h, p = 0.03, respectively). Decrease of hemoglobin levels was greater after the surgical procedure in the D&C group (p = 0.02). CONCLUSION: MVA caused less blood loss, was less time consuming, and resulted in shorter hospitalization. However, both surgical procedures were found to be efficient for treatment of incomplete abortions during the first trimester of pregnancy, with no complications after both treatments.

Monitoring medical abortion using mifepristone/misoprostol combination with ultrasonogram and serum human chorionic gonadotropin.

OBJECTIVE: The oral mifepristone/misoprostol combination (MMC) is safe for medical abortion in early pregnancy. The abortion status in MMC-treated pregnancies at Taipei Medical University-Wan Fang Medical Center was determined by ultrasonography, serum beta-human chorionic gonadotropin (beta-HCG), and histopathology. METHODS: All women at less than 49 days since the last menstruation who asked for legal abortion were evaluated by ultrasonography. They then received 600 mg of oral mifepristone followed 48 hours later by 600 microg of misoprostol. Women who had vaginal spotting or bleeding after 14 days were included in this study and underwent transvaginal ultrasonography, serum beta-HCG measurement and vacuum aspiration or therapeutic dilatation and curettage (D&C) on day 14. Specimens were identified by histopathology. Abortion status was determined from linear regression of serum beta-HCG and endometrial thickness. RESULTS: Of 35 women who underwent vacuum aspiration or therapeutic D&C, histopathology showed that 20 had decidual tissue and 15 had gestational tissue. Logistic regression showed that the distance measurement to the logistic regression line differed significantly between complete and incomplete abortion (p < 0.05). CONCLUSION: In this study, serum beta-HCG assays in addition to ultrasonographic evaluation helped to discriminate abortion status after oral MMC.

Glycodelin serum levels in women with ectopic pregnancy.

OBJECTIVE: Aim of our study was to determine circulating levels of glycodelin for biochemical monitoring of women with vaginal bleeding and/or abdominal pain in early pregnancy. The objective was, using glycodelin as a biochemical parameter, to distinguish between incomplete abortion and ectopic pregnancy in early weeks of gestation. STUDY DESIGN: In 169 women with a first trimester pregnancy, a single serum measurement of maternal glycodelin was taken. Patients were divided into groups according to the clinical and/or ultrasonografic findings at the time of hospitalisation:ectopic pregnancy, incomplete abortion and control. RESULTS: Glycodelin serum levels were significantly lower in patients with ectopic pregnancy comparable with intact pregnancy and incomplete abortion. There was no difference in serum levels between intact pregnancy and incomplete abortion. CONCLUSION: Glycodelin might represent a biochemical parameter in the differential diagnosis between ectopic pregnancies and incomplete abortion. The number of patients was too small to give reference ranges for pregnancy weeks.

[Maternal CA 125 serum level in intrauterine pregnancy and abortion in the first trimester]. / Mütterliche CA 125-Serumspiegel bei intrauterinen Schwangerschaften und Aborten im ersten Trimenon.

OBJECTIVE: Maternal CA 125 levels are supposed to rise in pregnancies complicated by vaginal bleedings in dependence to the extent of decidual disruption which is directly related to the outcome of pregnancy. MATERIAL AND METHODS: The prognostic value of maternal CA 125 serum measurement was investigated in 239 women with a first trimester intact pregnancy, imminent, incomplete, complete or missed abortion. RESULTS: 43.9% of the CA 125 serum levels were without normal range (> 20 U/ml). Mean CA 125 serum levels were higher in patients with incomplete (52.4 +/- 67.4 U/ml), complete (34.3 +/- 46.1 U/ml), and imminent abortion (33.0 +/- 45.8 U/ml) as compared with normal pregnancies (28.9 +/- 28.8 U/ml) and missed abortion (23.5 +/- 21.5 U/ml). CA 125 levels in first trimester pregnancies tended to be higher in patients with vaginal bleedings than in patients without bleeding (40.5 U/ml +/- 55.0 vs. 28.9 U/ml +/- 28.8; p = 0.65). CONCLUSIONS: For clinical use CA 125 serum measurement is not relevant. First trimester CA 125 measurement can not serve as an accurate predictor of pregnancy outcome due to the wide overlap of ranges.

[Secretion of hCG by mononuclear cells--a specific and essential reaction in pregnancy?]. / Sekretion von hCG durch mononukleäre Zellen--eine spezifische und essentielle Reaktion während der Schwangerschaft?

Mononuclear cells in peripheral blood secrete immunoreactive hCG (ir-hCG) when they are stimulated in in-vitro culture with the proteinkinase C - activator phorbol-myristat-acetate (TPA). We examined the ir-hCG secretion in 61 fertile and 191 pregnant women and 38 men. Mononuclear cells of pregnant women secrete after TPA stimulation significantly more ir-hCG than mononuclear cells on non-pregnant but fertile women. This effect can be detected as early as 23rd days of a menstrual cycle which is accompanied by conception and persisted over the entire duration of a pregnancy. Maximal effects were observed in the 7th to 19th and 30th to 34th weeks of pregnancy. An artefact caused by adhesive serum-hCG could be excluded. The elevated potential of the mononuclear cells to be stimulated remained intact for about 14 days after termination of a normal pregnancy in the first trimester. An ir-hCG secretion similar to that seen in nonpregnant women was found in patients with early abortion. The possible physiological importance of the in-vivo secretion of beta-HCG during pregnancy is discussed.

[Diagnosis of ovum viability: comparative analysis between ultrasound and chorionic gonadotropin hormone]. / Diagnóstico de vitalidad ovular: análisis comparativo entre ultrasonido y hormona gonadotropina coriónica.

In a retrospective study carried out in the Hospital de Gineco-Obstetricia del Centro Médico León, Gto., Instituto Mexicano del Seguro Social, 61 patients were studied in order to compare the sensitivity and specificity values and the correlation coefficient between the hormonal assays (Human Chorionic Gonadotropin, HCG) and the ultrasound scanning. The qualitative concentrations of HCG had a sensitivity of 37.5% and a specificity of 100%. The levels of subunit beta of HCG had sensitivity of 25% and specificity of 100%. The whole correlation coefficient of the hormonal method (HCG) was R = 0.51 (P less than 0.01). The ultrasound monitoring had a sensitivity of 855 and specificity of 100%, with a correlation coefficient R = 0.88 (P less than 0.01). It was concluded that ultrasound scanning has a better sensitivity and higher correlation than human chorionic gonadotropin assays in the diagnosis of ovum vitality.

Glycemic control and spontaneous abortion in insulin-dependent diabetic women.

Insulin-dependent diabetic women without adequate glucose control have a higher spontaneous abortion rate when compared with the general population. The present study examined whether the increased rate of spontaneous abortions in insulin-dependent diabetic women was associated with poor glycemic control in the early postconceptional period or close to the abortive event itself. Measurements of glycohemoglobin A1 at eight to nine weeks' gestation provide retrospective indexes of glucose control during the early postconceptional period, whereas measurement of glycosylated serum albumin and serum protein at the same time reflects short-term glycemic control before the abortive event. This study evaluated 84 consecutive pregnancies occurring in 68 insulin-dependent diabetic women; 66 pregnancies progressed beyond 20 weeks with no malformation or death, and 18 pregnancies terminated in spontaneous abortions before 20 weeks' gestation. The mean glycohemoglobin A1 concentrations of women experiencing spontaneous abortions were significantly greater than that of women who did not abort (P less than .05). In contrast, maternal glycosylated proteins and glycosylated albumin concentrations did not differ between groups. The authors suggest that poor control of diabetes in the early conceptional period, rather than that just before abortion, increases the risk of spontaneous abortion.

Use of beta-human chorionic gonadotropin in gestational aging.

Quantitative radioimmunoassay (RIA) of the beta chain of human chorionic gonadotropin (B-hCG) in serum has been used to evaluate the gestational status of 99 normal early pregnancies in contrast to 29 ectopic, threatened, aborted and/or terminated cases. Quantitative measurement of serum B-hCG-RIA standardized against the second international standard (2dIS) accurately established age of normal pregnancies in utero up to but not after three weeks postconception and with an accuracy of plus or minus four days between the third and eighth week of gestation. Quantitative urinary hCG-RIA standardized against the 2dIS were not useful for gestational aging. Useful serum hCG-RIA were identically linear and parallel with the 2dIS, had negligible crossreactivity with LH, FSH and/or TSH, and had low nonspecific binding. Of 13 hCG-RIA evaluated, only assays having these latter characteristics were able to detect ectopic pregnancies, spontaneous abortions, and/or threatened pregnancies with up to 90 percent accuracy. However, some assays not standardized to the 2dIS gave over 200 percent error in hCG serum values. Thus, correct choice of quantitative B-hCG reagents is necessary for early pregnancy assessment.

The value of ovarian and placental steroid determinations in abnormal early pregnancy.

Concentrations of estradiol (E2), progesterone (P), and 170H-progesterone (170H-P) were measured by radioimmunoassay in serum samples obtained from a group of 98 women with threatened (n = 60), incomplete (n = 22) or missed (n = 16) abortion between the 4th and 17th week of pregnancy. The diagnosis was based on the clinical symptoms and the results of ultrasound scanning. In threatened abortion 54, out of 60 E2 values were within the 95% normal range, including most of the cases in which abortion occurred later. In incomplete abortion 18 of 21 E2 values were below the lower 95% confidence limit. In missed abortion, 11 of 15 E2 values were abnormal, being below the 95% normal range. Similar patterns in women with threatened, incomplete or missed abortion can be observed for values of P and 170H-P. Our results indicate that serum determinations of ovarian and placental steroids in women with early pregnancy failure are not of great clinical value.

Unsuspected pregnancy loss in healthy women.

A sensitive and specific radioimmunoassay was used to determine human chorionic gonadotropin (hCG) in serum samples obtained from 91 normal healthy women during 226 ovulatory cycles in which contraception was not being practised. Known conceptions occurred in 85 of these cycles; 74 ended in the births of live normal babies and the remaining 11 aborted spontaneously. Vaginal bleeding occurred at the expected time on the remaining 141 occasions and was accepted as normal menstruation by the patients; but concentrations of hCG consistent with pregnancy were detected in the serum of 7 individuals. Expressed as a proportion of conceptions, about 8% of human pregnancies are lost at such an early stage of development that the patients are unaware that conception has occurred.

[Is prognostic information obtainable from serum PZ level with imminent abortion? (author's transl)]. / Gestattet der mütterliche Serum-PZ-Spiegel beim Abortus imminens cine prognostische Aussage?

Reported in this paper are 359 abortion patients and 550 women with normal pregnancy from whom serum PZ (pregnancy zone protein), SP3, PAG, was determined, between 1974 and 1979. Serum PZ failed to enable any safe prognostic assessment of endangerment to early pregnancy. Evaluable diagnostic information was found to be not obtainable before the tenth week of pregnancy. Any drop of data below the critical limit of 200 mg/l must be taken to indicate with high probability that pregnancy is no longer intact.