Relationship between the Volume Ratio of Subchorionic Hematoma to Gestation SAC in First-trimester and Pregnancy Outcome of Patients with Threatened Abortion.

OBJECTIVE: To find the relationship between the volume ratio of subchorionic hematoma (SCH) to gestation sac measured by three-dimensional ultrasound and pregnancy outcome of patients with threatened abortion. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: The Second Affiliated Hospital of Soochow University, Suzhou, China, from January 2016 to December 2020. METHODOLOGY: Medical data of patients, who were diagnosed with threatened abortion (persistent or intermittent vaginal bleeding) were collected. All included patients underwent ultrasonography for SCH at gestation age of 6-8 weeks. According to the patients' evaluation, they were classified into a case group combined with threatened abortion and SCH (n=145), and a control group with threatened abortion (n=76). The clinical data and three-dimensional ultrasound parameters of the two groups were compared to find the relationship between the volume ratio of SCH to gestation sac and pregnancy outcome. RESULTS: In the case group, the hospital stay was longer, the abdominal pain, its duration ≥7 days, and adverse pregnancy outcomes were higher than in the control group (p<0.05). Patients with moderate and severe area ratio and volume ratio of SCH to gestation sac were significantly related to higher abortion and stillbirth rates than patients with mild ratio (p<0.05). The area under the curve, sensitivity and specificity of the volume ratio of SCH to gestation sac in predicting abortion and stillbirth were higher than that of the area ratio of SCH to gestation sac. CONCLUSION: The volume ratio of SCH to gestation sac by three-dimensional ultrasound in first-trimester plays an important role to predict pregnancy outcome. KEY WORDS: Ultrasonography, Hematoma, Pregnancy outcome, Threatened abortion, ROC curve.

Plasma and amniotic fluid concentrations of nitric oxide: Effects on uterine artery and placental vasculature in women who underwent voluntary pregnancy termination and in women with missed and threatened abortion. A pilot study.

OBJECTIVES: First trimester miscarriage is a multifactorial event. Various angiogenic factors have been proposed as possible early markers of non-viable pregnancies. The aim of the present study was to evaluate the systemic nitric oxide (NO) production in healthy early pregnancy and its possible role in first trimester miscarriage. STUDY DESIGN: We prospectively enrolled women referred to our Unit for elective termination of pregnancy, threatened abortion or missed abortion. Blood samples were taken for testing circulating NO plasma levels. Subsequently, all patients underwent 2-D ultrasonographic analysis and Color Doppler imaging to assess the pulsatility index of the uterine arteries. 3-D ultrasonographic and power Doppler analysis allowed a volumetric and vascular reconstruction of the placenta. During dilatation and vacuum aspiration, amniotic fluid was collected. RESULTS: Seventy-two patients were enrolled: 25 with elective termination of pregnancy (Group I); 17 with threatened abortion (Group II); 30 with missed abortion (Group III). Group II showed greater placental volume and lower uterine arteries PI than others. The plasma NO concentration resulted statistically higher in women with threatened abortion, while amniotic fluid NO concentration were higher in the viable pregnancies (Group I) than in the aborted fetuses (Group III). Plasma NO was inversely correlated with both mean arterial pressure and uterine artery PI and was positively correlated with amniotic fluid NO and CRL; amniotic fluid NO was positively correlated with placental Vascularization Index and Vascularization-Flow Index. CONCLUSION: Amniotic NO concentration was higher in viable pregnancies and positively related to Doppler 3D indices of vascularization and blood flow within the placenta. Further studies are needed to elucidate its role in first trimester miscarriage.

Placenta increta presenting with threatened miscarriage during the first trimester in rhesus-negative mother: a case report.

BACKGROUND: Placenta accreta is known to be associated with significant maternal morbidity and mortality-primarily due to intractable bleeding during abortion or delivery at any level of gestation. The complications could be reduced if placenta accreta is suspected in a patient with a history of previous cesarean delivery and the gestational sac/placenta is located at the lower part of the uterus. Then, a proper management plan can be instituted, and complications can be reduced. The diagnosis of placenta accreta in the first trimester of pregnancy is considered uncommon. CASE PRESENTATION: A 34-year-old Malay, gravida 4, para 3, rhesus-negative woman was referred from a private hospital at 13 weeks owing to accreta suspicion for further management. She has a history of three previous lower-segment cesarean sections. She also had per vaginal bleeding in the early first trimester, which is considered to indicate threatened miscarriage. Transabdominal ultrasound revealed features consistent with placenta accreta spectrum. She was counseled for open laparotomy and hysterectomy because of potential major complication if she continued with the pregnancy. Histopathological examination revealed placenta increta. CONCLUSION: A high index of suspicion of placenta previa accreta must be in practice in a patient with a history of previous cesarean deliveries and low-lying placenta upon ultrasound examination during early gestation.

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.

No. 375-Clinical Practice Guideline on the Use of First Trimester Ultrasound.

OBJECTIVE: This guideline reviews the clinical indications for first trimester ultrasound. OUTCOME: Proven clinical benefit has been reported from first trimester ultrasound. EVIDENCE: A Medline search and bibliography reviews in relevant literature provided the evidence. VALUES: Content and recommendations were reviewed by the principal authors and the Diagnostic Imaging Committee of the Society of Obstetricians and Gynaecologists of Canada. Levels of evidence were judged as outlined by the Canadian Task Force on Preventive Health Care.

Doppler and biochemical assessment for the prediction of early pregnancy outcome in patients experiencing threatened spontaneous abortion.

OBJECTIVE: To evaluate the usefulness of Doppler indices of the corpus luteum and uterine artery in combination with serum progesterone and cancer antigen 125 (CA125) as prognostic tools in first-trimester threatened spontaneous abortion. METHODS: Pregnant women with threatened spontaneous abortion at a pregnancy duration 8-10 weeks were enrolled into an observational prospective clinical trial at a university hospital in Egypt during 2015. Doppler indices (uterine artery/corpus luteum resistance index and pulsatility index) and biochemical markers (CA125, progesterone) were determined and compared by pregnancy outcome (spontaneous abortion vs continuing pregnancy at 20 weeks). RESULTS: Of 100 women included, 16 had a spontaneous abortion. These women had a higher CA125 value than did women without an abortion (P<0.001), whereas the progesterone level among women with an abortion was lower (P<0.001). The Doppler indices were not significantly different between the groups, but calculation of the uterine artery resistance index as a percentage of the normal standard value at a given pregnancy duration revealed significant differences (P<0.001) between the two groups. CONCLUSION: Serum progesterone and CA125 are useful provisional predictors of spontaneous abortion, whereas the Doppler indices are not. The two biomarkers could be used as a basis to counsel anxious couples. CLINICALTRIALS.GOV: NCT02420769.

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.

Ultrasound Evaluation of First Trimester Complications of Pregnancy.

OBJECTIVE: OUTCOMES:: EVIDENCE: A MEDLINE search and review of bibliographies identified articles was conducted. VALUES: The evidence collected was reviewed by the Diagnostic Imaging Committee of the Society of Obstetricians and Gynaecologists of Canada. The recommendations were made according to the guidelines developed by The Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS: Women presenting with first trimester bleeding may be incorrectly diagnosed with a missed abortion, may have an ectopic pregnancy overlooked, or may be inappropriately reassured about viability. Improvement in the identification of the sonographic landmarks of normal embryonic development and awareness of the sonographic risk factors of pregnancy failure may lead to more case-specific management strategies. Diagnosis of suspected ectopic pregnancy often involves an assessment of both hormonal markers and sonographic features. Maternal morbidity and mortality can be reduced with an early diagnosis of ectopic pregnancy.

[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.

Fetal loss in threatened abortion after demonstration of fetal cardiac activity in a low socioeconomic population.

This study was conducted to determine the incidence and risk factors of fetal loss in threatened abortion after ultrasonographic detection of fetal cardiac activity in a low socioeconomic population. A total of 202 women with singleton pregnancies who presented with vaginal bleeding in which fetal heart activity was ultrasonographically demonstrated between 5 and 14 weeks' gestation were included. Pregnancies with fetal abnormalities were excluded from the study. All cases were followed-up with respect to pregnancy outcomes. A total of 54 of 202 pregnancies (26.7%) resulted in fetal loss before 20 weeks' gestation. The mean fetal heart rate (FHR) and cervical length values were lower in spontaneous abortions than in viable pregnancies (121.2 +/- 13.3 vs 143.5 +/- 12.4 and 41 +/- 6.0 vs. 34.8 +/- 6.1, respectively; p < 0.001). A receiver operating characteristic (ROC) curve analysis revealed an area under the curve of 0.88 for FHR and 0.77 for cervical length. A FHR value <130 b.p.m. was 81.4% sensitive, 85.1% specific and a cervical length value <40 mm was 80.8% sensitive, 54.7% specific for determination of fetal loss before 20 weeks' gestation. Fetal loss was observed in about one-quarter of pregnancies admitted with threatened abortion in a low socioeconomic population. Bradycardia and short cervix were found to be significant risk factors affecting the pregnancy outcome in women presenting with vaginal bleeding, in whom fetal cardiac activity was documented.

"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.

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.

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.

[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.

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.