Value of routine transvaginal ultrasound scan in women requesting early termination of pregnancy.

This was a retrospective study of 140 women attending a termination clinic from 1 April 2002 to 31 March 2003. All women had a transvaginal ultrasound scan. Of 140 women, 56 women benefited from the scan; 26.7% had non-viable pregnancy, 35.71% did not remember their LMP, 12.5% had discrepancy between the scan and LMP. Incidental findings were noted in 24.6% of which two had a twin gestation, nine had ovarian cysts, one had an ectopic pregnancy, one had a hydatidiform mole, one conceived with an IUCD and one had a bicornuate uterus with pregnancy in one horn. Two of the nine women with ovarian cysts needed a laparotomy. This study concludes that routine transvaginal scan (TVS) scan is an essential investigation for proper assessment of all women requesting termination of pregnancy. TVS is a safe and effective procedure which provides useful information regarding gestational age, viability of pregnancy and uncertain dates. In cases of the ectopic pregnancy and the hydatidiform mole transvaginal ultrasound helped us in appropriate management from the outset and minimised complications.     

Effect of vaginal bleeding in early pregnancy on outcome

The effect of vaginal bleeding in the first half of pregnancy on fetal outcome is retrospectively analyzed in 523 cases and compared with a control group of 6706. Early-pregnancy bleeding was found to be associated with more preterm deliveries and lower birth weight. The frequency of congenital anomalies and growth-retarded infants was unaffected. Neonatal death and low Apgar scores were seen more often than expected, but stillbirth rates were not significantly increased. These data suggest that vaginal bleeding in early pregnancy is a useful indicator of risk for suboptimal outcome.     

Cervical pregnancy ending in a live vaginal birth

A case of cervical pregnancy followed by cataclysmic haemorrhage estimated at 8500 ml and necessitating total abdominal hysterectomy and replacement of 18 units of blood is reported. This pregnancy remained undiagnosed until 28 wk and is to our knowledge the first case described in the English literature in which the pregnancy ended in a live vaginal birth. Both mother and baby are now well.     

Epidural analgesia during labour with a singleton alive fetus at term

OBJECTIVE: Whether epidural analgesia (e.a.) have influence on the way of delivery, indications to cesarean section (c.s.) and neonatal outcome. MATERIAL AND METHODS: We have analysed 8784 deliveries. We excluded women with plural pregnancy, pre-term parturitions, elective c.s., still births. Finally we studied 339 parturitions with e.a. versus 6868 the others and theirs newborns. RESULTS: More frequent c.s. was in women with e.a. (18.6% vs 7.9%; p < 0.001) or forceps (f.d.) (7.7% vs 3.5%; p < 0.005). Among those with e.a. the most frequent indications to c.s. were labour with no progression (23.4% vs 4.0%; p < 0.001) and the others as hypoxia fetus (68.7% vs 82.6%; p < 0.01). The lost of blood with oblique to transfusion was more frequent at f.d. at comparison to c.s. and spontaneous delivery (26.9% vs 3.2% and 6.8%; p < 0.001). The condition of neonates at 1 min. according Apgar score was the worse after f.d. in comparison to spontaneous delivery (7.38 +/- 2.22 vs 8.79 +/- 1.41 points; p < 0.005) and after c.s. (7.38 +/- 2.22 vs 8.55 points; p < 0.05). In comparison the state at 5 min. was the similar after f.d. (9.11 +/- 1.24 vs 9.53 +/- 0.81 points; p = 0.05) and (9.11 +/- 1.24 vs 9.48 +/- 0.83 points; p = 0.09). CONCLUSIONS: Women with epidural analgesia more frequent were ending the delivery by cesarean section or forceps. The forceps delivery was related with worse neonatal outcome at first minutes of live, and bigger lost of blood during labour. Epidural analgesia predisposed to cesarean section delivery caused of partus without progress and relatively deminished caused by fetus hypoxia.     

Midwifery management of first trimester bleeding and early pregnancy loss

As many as 25% of women experience bleeding in the first and early second trimester of pregnancy; about half of these will have a miscarriage or, more rarely, ectopic or molar pregnancy loss. This can be a difficult time for women because of the uncertainty of the outcome, lack of preventative measures, and emotional significance of early pregnancy loss. The qualities that characterize midwifery care, including providing complete information, encouraging self-determination, and being sensitive to the emotional state, are particularly important at this time. This article reviews the epidemiology; physiologic process; signs and symptoms of first trimester bleeding; miscarriage and other early pregnancy losses; and methods of clinical, biochemical, and sonographic evaluation. A framework to guide midwifery evaluation and management, based on confirmation of an intrauterine pregnancy followed by the determination of viability, is presented. Surgical, medical, and expectant management of nonviable pregnancy, management of viable pregnancy when bleeding persists, and follow-up care, including screening for psychological sequelae, are discussed. Case studies and specific clinical guidelines for midwifery care, consultation, collaboration, and referral are included. Understanding the emotional significance of first trimester bleeding and loss as a basis for sensitive care throughout the management process is addressed.     

The role of ultrasound imaging in detecting endometrial cancer in postmenopausal women with vaginal bleeding

Approximately 10% of women with postmenopausal bleeding have endometrial cancer, the most common reproductive organ malignancy among women in the United States. The use of transvaginal ultrasonography allows the clinician to identify women at risk for endometrial cancer and triage them to an appropriate procedure for a histologically confirmed diagnosis.     

Risk of preterm delivery in relation to vaginal bleeding in early pregnancy

OBJECTIVE: To examine the relationship between vaginal bleeding during early pregnancy and preterm delivery. METHODS: Study subjects (N=2678) provided information regarding socio-demographic, biomedical, and lifestyle characteristics. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (95% CI). RESULTS: Any vaginal bleeding in early pregnancy was associated with a 1.57-fold increased risk of preterm delivery (95% CI: 1.16-2.11). Vaginal bleeding was most strongly related with spontaneous preterm labor (OR=2.10) and weakly associated with preterm premature rupture of membrane (OR=1.36) and medically induced preterm delivery (OR=1.32). As compared to women with no bleeding, those who bled during the first and second trimesters had a 6.24-fold increased risk of spontaneous preterm labor; and 2-3-fold increased risk of medically induced preterm delivery and preterm premature rupture of membrane, respectively. CONCLUSION: Vaginal bleeding, particularly bleeding that persists across the first two trimesters, is associated with an increased risk of preterm delivery.     

Evaluation of coagulation abnormalities among women with vaginal bleeding in the first trimester of pregnancy

ObjectiveTo compare blood coagulation parameters between pregnant women with vaginal bleeding in the first trimester of pregnancy and pregnant women with normal pregnancy in the first trimester.MethodsA prospective controlled study of 98 women in the first trimester of vital pregnancy was conducted at the University Medical Centre Maribor, Slovenia. The study group comprised women with vaginal bleeding (n = 50) while the control group women with normal pregnancy, admitted for artificial abortion (n = 48). Prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen concentration, number of platelets, hemogram, coagulation factor VIII (FVIII) and von Willebrand factor (VWF) activity were compared between the 2 groups.ResultsNo significant between-group differences were detected in mean PT, fibrinogen concentration, FVIII, and VWF activity. Mean aPTT was significantly higher in the control group than the study group (32.47 versus 30.46 seconds; P < 0.05). The mean number of platelets was significantly lower in the study group than the control group (181.69 versus 203.52 × 10⁹/L; P < 0.05). All measured coagulation parameters, except VWF activity, were within normal ranges.ConclusionCoagulation abnormalities are rarely the cause of vaginal bleeding in the first trimester of pregnancy among women with no previous symptoms of bleeding disorders.     

Evidence of placental abruption as a chronic process: associations with vaginal bleeding early in pregnancy and placental lesions

BACKGROUND: Clinicians widely regard placental abruption as an acute event, though accumulating data point towards abruption being the end-result of chronic processes early in pregnancy, and perhaps even extending to conception. The Collaborative Perinatal Project was a prospective cohort study performed from 1959 to 1966 in the United States. Since enrolled pregnancies were managed without the biases created by modern perinatal surveillance and interventions, the natural history of disease in these data is ideal to study obstetrical complications such as placental abruption. OBJECTIVE: We assessed the associations versus contributions of the clinical feature of early gestational vaginal bleeding and histologic lesions (chronic and acute) with placental abruption. STUDY DESIGN: Women enrolled in the Collaborative Perinatal Project (1959-1966) were used, restricting the analysis to those that delivered singleton births (n=46,364). Risks of placental abruption were compared between women with and without vaginal bleeding at <20 weeks gestation. We also examined the relationships between placental abruption and chronic and acute histologic lesions, including infarcts, decidual necrosis, presence of macrophages in the decidua, amnion or chorion, and neutrophil infiltration in the amnion, chorion, placental surface, and umbilical vein. RESULTS: Any episode of vaginal bleeding at <20 weeks in pregnancy conferred an increased risk of placental abruption (adjusted relative risk (RR) 1.6, 95% confidence interval (CI) 1.3, 1.8). The greatest risk occurred with bleeding in both the first two trimesters (RR 3.1, 95% CI 2.3, 4.1). The presence of histologic lesions in the placenta, cord and membranes similarly carried an increased risk of placental abruption, even in the absence of vaginal bleeding. The risk of abruption was, however, highest in the presence of both histologic lesions and vaginal bleeding early in pregnancy. CONCLUSION: Vaginal bleeding early in pregnancy and histologic lesions of the placenta, umbilical cord, and membranes are associated with increased risk of placental abruption in later pregnancy. However, the increased risk associated with placental lesions, especially chronic inflammatory lesions, even in the absence of early vaginal bleeding, suggests that prolonged inflammation may be implicated in placental abruption.     

Relationship of vaginal bacteria and inflammation with conception and early pregnancy loss following in-vitro fertilization

OBJECTIVE: The aim of this study was investigate the impact of vaginal flora and vaginal inflammation on conception and early pregnancy loss following in-vitro fertilization (IVF). METHODS: We enrolled 91 women who were undergoing IVF. At embryo transfer (ET), all of the women had quantitative vaginal culture, ET catheter-tip culture, and vaginal Gram stain scored for bacterial vaginosis and quantitated for polymorphonuclear leukocytes (PMNs). Conception and early pregnancy loss were compared with culture and Gram stain results. Statistical analyses included the Chi-square test, Fisher's exact test and the Mann-Whitney U-test. RESULTS: The overall live birth rate (LBR) was 30% (27/91), and the rate of early pregnancy loss was 34% (14/41). In women with bacterial vaginosis, intermediate flora and normal flora, the conception rates were 30% (3/10), 39% (12/31) and 52% (26/50), respectively (p = 0.06 for trend). Early pregnancy loss occurred in 33% (1/3), 42% (5/12) and 31% (8/26) of women, respectively (p = 0.06, comparing intermediate and normal flora). The vaginal log concentration of hydrogen peroxide-producing lactobacilli was 7.3 +/- 1.7 in women with a live birth (n = 27) and 4.9 +/- 2.5 in those with early pregnancy loss (n = 14) (p = 0.1). CONCLUSIONS: IVF patients with bacterial vaginosis and with a decreased vaginal log concentration of hydrogen peroxide-producing lactobacilli may have decreased conception rates and increased rates of early pregnancy loss. A larger prospective treatment trial designed to evaluate the impact on IVF outcomes of optimizing the vaginal flora prior to IVF may be warranted.     

Prediction of neonatal metabolic acidosis in women with a singleton term pregnancy in cephalic presentation

We sought to predict neonatal metabolic acidosis at birth using antepartum obstetric characteristics (model 1) and additional characteristics available during labor (model 2). In 5667 laboring women from a multicenter randomized trial that had a high-risk singleton pregnancy in cephalic presentation beyond 36 weeks of gestation, we predicted neonatal metabolic acidosis. Based on literature and clinical reasoning, we selected both antepartum characteristics and characteristics that became available during labor. After univariable analyses, the predictors of the multivariable models were identified by backward stepwise selection in a logistic regression analysis. Model performance was assessed by discrimination and calibration. To correct for potential overfitting, we (internally) validated the models with bootstrapping techniques. Of 5667 neonates born alive, 107 (1.9%) had metabolic acidosis. Antepartum predictors of metabolic acidosis were gestational age, nulliparity, previous cesarean delivery, and maternal diabetes. Additional intrapartum predictors were spontaneous onset of labor and meconium-stained amniotic fluid. Calibration and discrimination were acceptable for both models (c-statistic 0.64 and 0.66, respectively). In women with a high-risk singleton term pregnancy in cephalic presentation, we identified antepartum and intrapartum factors that predict neonatal metabolic acidosis at birth.     

Management of early pregnancy loss.

OBJECTIVES: In order to assess the available evidence on the management of early pregnancy loss, we performed a meta-analysis on the subject. METHODS: MEDLINE and EMBASE were searched for randomized studies reporting on the effectiveness of expectant management, misoprostol treatment or curettage. Outcomes considered were 'complete evacuation', complications, duration of bleeding, pain resulting from the procedure, side effects and women's satisfaction with the procedure. RESULTS: Thirteen studies were identified. Combined data in women with missed abortion managed expectantly or treated with misoprostol showed complete evacuation rates of 28% (49/173) (range 14-47%) and 81% (242/298) (range 60-83%), respectively. In women with incomplete abortion, these rates were 94% (31/33) (range 80-100%) and 99% (75/76) (range 99-100%), respectively. CONCLUSION: In the management of early pregnancy loss both expectant management and misoprostol treatment reduce the need for curettage, but misoprostol treatment seems to be more effective in women with missed abortion as compared to expectant management.