Biochemical and ultrasonographic predictors of outcome in threatened abortion

ObjectivesTo evaluate different biochemical and ultrasonographic markers as predictors of outcome in cases with threatened abortion.Study designA prospective observational study involving 250 women in their 1st trimester was divided into three groups: group I (65 women) in whom threatened abortion ended in abortion, group II (85 women) with threatened abortion who completed their pregnancy and group III (100 women) with normal pregnancy. Biochemical markers studied included CA 125, beta human chorionic gonadotropin (β HCG), progesterone, Estradiol (E2), Lactate dehydrogenase (LDH), and Total leucocytic count (TLC) and ultrasonographic markers included Embryonic/Fetal heart rate (E/FHR), Gestational sac diameter (GSD), Crownrump length (CRL) and Yolk sac diameter (YSD). Comparison between markers was done using sensitivity, specificity, PPV and NPV.ResultsThere was a statistically significant difference between GI and the other two groups regarding CA 125 β HCG, progesterone, FHR and CRL.There was no significant difference between the three study groups regarding E₂ level, LDH, TLC, GSD or yolk sac diameter.The sensitivity, specificity, PPV and NPV of CA 125 at 80 IU/ml were 80.2, 78.3, 69.6 and 82.4, respectively, for β HCG at 19887 mIU/ml were 88.6, 81.1, 45,6 and 96.8, respectively, for Progesterone at 25 ng/ml were 90.1, 87.2, 51,2 and 97, respectively, for FHR at 110 bpm were 98.1, 99.1, 89,2 and 91.4, respectively and for CRL at 21 mm were 46.4, 40.1, 35,5 and 33.7, respectively.ConclusionCA125, β HCG and progesterone are good biochemical markers and FHR and CRL are good ultrasonographic markers for the prediction of outcome in women with threatened abortion. FHR at 110 bpm gives the best predictivity followed by serum P at 25 ng/ml, β HCG at 19887 mIU/ml, CA 125 at 80 IU/ml and CRL at 21 mm with the least predictive accuracy among studied markers. Adding serum progesterone to FHR gave a sensitivity and specificity of 100%.     

Decreased fetal activity and fetal heart rate changes after amniocentesis complicated by fetal hemorrhage

A case is described in which amniocentesis caused placental injury, abruptic placenta, and fetal hemorrhage which caused fetal distress. This was primarily manifested by reduction of fetal movements and later by fetal heart rate deceleration. Emergency cesarean section was performed of monitoring the fetus after amniocentesis by assessment of fetal movements is stressed.     

Uterine artery Doppler and urinary hyperglycosylated HCG as predictors of threatened abortion outcome

ObjectiveTo study the role of uterine artery Doppler and urinary hyperglycosylated hCG (hCG-H) in predicting threatened abortion outcome.MethodsA prospective observational study was conducted on 93 cases with threatened abortion (study group) and 50 cases with normal pregnancy (control group) at 6–12 weeks of gestation. Uterine artery Doppler examination was performed and urinary hCG-H was measured in all cases. Cases were followed up till delivery and the number of aborted cases was recorded.ResultsUrinary hCG-H concentration was significantly higher in the control group and in cases who continued than in cases who miscarried 5.3 ± 3.9 vs. 2.1 ± 3.0 mIU/ml equivalents (P = 0.002) for the first and 5.1 ± 4.5 vs. 2.1 ± 3.0 mIU/mlEq (P = 0.003) for the second respectively. The ratio of hyperglycosylated hCG to total hCG was >51% in the 116 term outcome cases while it was below 49% in the 29 cases who miscarried. Unilaterally increased uterine artery pulsatility index and Δ uterine artery pulsatility index values were significantly higher in women who miscarried than in those with continuing pregnancies or the control groups (P < .0001). ROC for uterine artery Doppler revealed an area under the curve AUC of 0.77, while for urinary HCG-H the AUC was 0.82 and for uterine artery Doppler and urinary HCG-H combined the AUC reached 0.93.ConclusionThe unilaterally increased uterine arteries pulsatility index and the decreased urinary hCG-H production in the first trimester could predict miscarriage in threatened abortion.     

Fetal hiccups; characteristics and relation to fetal heart rate

In 35 two-hour recordings of fetal heart rate and fetal movements, 14 periods of fetal hiccups were present (1.2% of the recording time) with a median duration of 3.5 min (range 1 to 8 min). No specific relation to behavioural states or movement patterns could be identified. The hiccupping frequency varied from 10 to 21 per min. Within a hiccupping spell, the mean frequency decreased from 20 ± 11 to 12 ± 6.2 per min. A small but evident increase in baseline frequency was present during the hiccupping spells, independent from other movements performed by the fetus.     

The detection of anti-beta2-glycoprotein I antibodies is associated with increased risk of pregnancy loss in women with threatened abortion in the first trimester

OBJECTIVE: This study was designed to evaluate whether the detection of serum antiphospholipid autoantibodies may be useful in predicting pregnancy outcome in women with threatened abortion in the first trimester. STUDY DESIGN: A group of 77 pregnant women of between 8 and 12 weeks' gestation with vaginal bleeding was tested for serum antiphospholipid, lupus anticoagulants, anticardiolipin, antinuclear antibodies, and anti-beta2-glycoprotein I antibodies, and was followed up until the spontaneous end of pregnancy. A control group composed of 15 healthy women with uncomplicated gestation was tested contemporarily for the same antibody panel. RESULTS: Of the 77 patients with threatened abortion, 32 (41.5%) progressed to deliver at term and 45 (58.5%) experienced early pregnancy loss. Among the antibodies evaluated, only anti-beta2-glycoprotein I was significantly more frequent in those women whose pregnancy resulted in spontaneous abortion (22/45, 49%) than in those who progressed to term (6/32, 19%) or in the control group (2/15, 13%; p=0.004). This difference was specific to the IgM isotype (p=0.001). After adjustment by multivariate analysis, the odds ratio for pregnancy loss associated with a positive beta2-glycoprotein I antibody test was 5.18 (p=0.001). CONCLUSION: The detection of anti-beta2-glycoprotein I antibodies is associated with an increased risk of pregnancy loss in women with threatened abortion in the first trimester.     

复发性流产患者早期妊娠胚胎丢失的预测

复发性流产(RSA)在我国指与同一配偶连续发生3次或以上的自然流产。80%以上的自然流产胚胎丢失发生于早孕时期,因此,对于再次妊娠的RSA患者,在早孕阶段正确预测其胚胎丢失可能,有助于调整患者保胎方案,提高妊娠成功率,降低保胎患者的经济、精神负担。文章结合相关文献,简述临床上或实验室预测早期胚胎丢失的指标。     

振动声音刺激引起胎动胎心率加速对预测胎儿预后的意义

本文对319例单胎足月孕妇进行振动声音刺激试验(VAS—T)及声刺激引起的胎动(SPFM)与传统的无负荷试验(NST)对预测胎儿预后的临床意义进行前瞻性对比研究。结果三者的阴性预测价值及敏感性均很高。VAS—T及SPFM的特异性、阳性预测价值均明显高于NST,而假阳性率显著低于NST,且大大缩短了试验时间,表明VAS—T及SPFM是有效、简便、省时、经济的产前胎儿监护方法。     

黄体功能不全先兆流产的治疗及血清孕酮值与治疗结局的相关性分析

目的:比较两种不同方式治疗黄体功能不全先兆流产的疗效及其血清孕酮值与治疗结局的相关性。方法:将301例患者分为两组:口服组217例(口服黄体酮胶囊100mg/次,2次/d)和肌注组84例(肌肉注射黄体酮20mg/次,1次/d)。每周复查血清孕酮值、β-HCG及B超。两组患者均治疗2~3周,随访至停经12周。结果:两组患者的血清孕酮值、治疗成功率比较,差异无统计学意义(P﹥0.05)。当孕酮界限值设为10ng/ml,口服组的敏感性和特异性分别为11.43%和97.25%,肌注组分别为41.67%和97.22%。当孕酮界限值设为15ng/ml,口服组的敏感性和特异性分别为85.71%和95.60%,肌注组分别为91.67%和94.44%。当孕酮界限值设为20ng/ml,口服组的敏感性和特异性分别为91.43%和23.08%,肌注组分别为91.67%和41.67%。结论:治疗妊娠早期黄体功能不全先兆流产,口服和肌注黄体酮均是有效且易于为阴道流血患者接受的黄体支持方法,口服比肌注方便、无疼痛刺激。黄体支持虽可升高血清孕酮水平,但血清孕酮值仍是一个较为可靠的预测治疗结局的指标,血清孕酮15ng/ml对自然流产的预测性更好。     

A comprehensive screening analysis of antiphospholipid antibodies in Indian women with fetal loss

OBJECTIVE: The present study was aimed at a comprehensive analysis of acquired thrombophilia in a large series of Indian women with fetal loss. STUDY DESIGN: Four hundred and thirty women (median age 26 years, range 18-39 years) with unexplained fetal loss (median number of abortions 3, range 1-13) were screened for the presence of antiphospholipid antibodies (APA), i.e. lupus anticoagulant (LA), IgG/M antibodies for cardiolipin (ACA), beta 2 glycoprotein 1 (beta2 GP1) and annexin V. We also studied 100 normal healthy women (median age 24 years, range 18-30 years) who had at least one healthy child and did not have any miscarriage or other obstetric complications. RESULTS: The prevalence of persistently positive LA was 8.1% and 1% in the patients and controls, respectively (OR 8.7; 95% CI, 1.4-51; P<0.05). The overall prevalence of IgG and/or IgM antibodies for cardiolipin, beta 2 GP1 and annexin V were as follows-ACA 27.9% (OR 18.9; 95% CI, 5-70; P<0.05), beta 2 GP1 12.2% (OR 6.8; 95% CI, 1.8-25; P<0.05) and annexin V 14.6% (OR 17; 95% CI, 2.9-98; P<0.05). The conventional LA and ACA tests were positive 23.2% of the cases as against 1% in the controls (OR 14.8; 95% CI, 3.9-55; P<0.05). The prevalence of LA, ACA, beta 2 GP1 and annexin V antibodies as independent risk factors were observed in 0.5%, 16.5%, 5.4% and 7.8% in the patients as against 1% each in the controls. The overall positivity for any one of the APA studied was 42.6% (OR 10.2; 95% CI, 4.5-23; P<0.05). CONCLUSION: The present study thus indicates the importance of APA in women experiencing fetal loss where all the conventional causes of miscarriages have been ruled out. It also suggests that conventional APA assays (LA and ACA) are effective in the detection of a majority of APA positive cases and by the addition of other cofactor-dependent (beta 2 GP1 and annexin V) APA assays, there is a considerable increase in the diagnostic efficiency in the detection of APA.     

Comparison of perinatal grief after dilation and evacuation or labor induction in second trimester terminations for fetal anomalies

OBJECTIVE: This study was undertaken to compare grief resolution after dilation and evacuation (D&E) or induction of labor (IOL) for second-trimester pregnancy termination. STUDY DESIGN: A prospective cohort of 49 women choosing second-trimester abortion caused by fetal anomalies by either medical IOL or D&E. Depression was evaluated by using the Edinburgh Postnatal Depression Scale and bereavement was assessed by using the Perinatal Grief Scale with follow-up to 12 months after pregnancy termination. Data were analyzed with chi 2 tests, Mann-Whitney U tests, and independent and paired sample t tests. RESULTS: There was no significant difference in depression incidence on enrollment (61.9% D&E, 53.8% IOL, P = .579), at 4 months (23.5% D&E, 14.3% IOL, P = .252) or 12 months (27.3% D&E, 20.0% IOL, P = .696) or on the PGS at 4 months (74.1 vs 90.2, P = .351) or 12 months (73.3 vs 86.4, P = .658). CONCLUSION: There is no significant difference in grief resolution among women who terminate a desired pregnancy by either medical or surgical abortion.     

Slow fetal heart rate may predict pregnancy outcome in first-trimester threatened abortion

Two hundred forty pregnant women presented with first-trimester threatened abortion were examined by transvaginal ultrasound. Women with a slow fetal heart rate of less than 120 beats per minute may eventually be at increased risk for pregnancy loss.     

Human placental lactogen, pregnancy-specific beta-1-glycoprotein and alpha-fetoprotein in serum in threatened abortion

The predictive value of HPL, SP1 and AFP in serum were determined in 109 women admitted to hospital because of vaginal bleeding in the 6th to 19th gestational week. The prediction of abortion based on the initial analysis from the day of admission was found to be 91.7%, 75.9% and 81.8% for HPL, SP1 and AFP, respectively. The corresponding values for prediction of successful outcome were 68.7%, 73.6% and 65.4%. The HPL and AFP determinations were, however, found to be valid only after the 9th and 12th gestational week, respectively. A highly significant positive correlation (r = 0.84, P less than 0.001) was demonstrated between HPL and SP1 suggesting that SP1 measurements might replace HPL in the evaluation of the prognosis in threatened abortion.     

Previous experience of induced abortion as a risk factor for fetal death and preterm delivery

As part of a community-based study in Korea to evaluate the effects of previous induced abortion on length of gestation and pregnancy outcome of subsequent pregnancies, we analyzed data obtained from January 1979 to December 1981 on pregnancies reported to family health workers in Kang Hwa Island, Korea. The preterm, live-birth rates were not significantly associated with previous induced abortion. Overall, the life table-estimated fetal death rate for women enrolled at the eighth or earlier weeks of gestation was 13.7%, 10.2% for women with no previous induced abortion and 28.9% for women with previous induced abortion. The relative risk for fetal death for women who had undergone a previous abortion was 2.8; relative risk for parous women compared to nulliparous women was 3.4. After controlling for parity, previous induced abortion was not a significant variable for fetal death rate.     

Fetal heart rate after vibroacoustic stimulation

Objective

To define reference ranges for fetal heart rate (FHR) parameters after vibroacoustic stimulation (VAS) according to gestational age by determining the relationship between FHR and gestational age using a computerized analysis system.

Methods

Data were analyzed from 3453 women using 10-minute observational recordings during nonstress testing (NST) and VAS testing. FHR parameters were analyzed according to gestational age.

Results

All FHR parameters were related to gestational age except for mean baseline FHR, which did not vary significantly with gestational age. All other parameters followed trends similar to the NST results, except for decelerations.

Conclusion

FHR parameters after VAS differed significantly according to gestational age. The results suggest that the gestational age of the fetus should be considered when interpreting FHR patterns after VAS.     

Identification and treatment of intra-abdominal fetal skeletal remains: A consequence of illicit and unsafe abortion

Abstract

Objective The safety of abortions has always been a matter of concern for women's health. Unsafe abortion is one of the most neglected health-care problems in developing countries due to lack of awareness of the legal issues and limited access to authorised services often leading the women to poor quality of abortion in unsafe settings through untrained health personnel.

Case report Two rare cases of second trimester unsafe abortions are reported here in which women presented after several weeks with well-preserved remains of fetal skeleton in their abdomen along with complicated multiple visceral injuries. Both these second trimester abortions were performed by untrained village abortionists for sex selection and unwanted pregnancy in an unmarried adolescent girl. The management in the unmarried girl was further complicated due to undisclosed history of abortion.

Conclusion These reports of unsafe abortion highlight the need for clinicians to have a high index of suspicion for an undisclosed abortion when treating any morbid woman of reproductive age with a bizarre abdominal clinical picture.

Chinese Abstract

摘要：

目的： 人工流产的安全性一直是女性健康关注的问题。不安全流产是发展中国家最容易被忽视的健康问题之一,因为这些国家的女性缺乏法律意识、授权服务受限,流产设备安全性差,卫生人员未经训练,最终导致女性流产质量低劣。

病例报告：文中报道了孕中期不安全流产的两个罕见病例,这两名女性在流产后几周腹部还有保存完好的胎儿骨骼,且并发多脏器损伤。这两个孕中期妊娠流产均由未经训练的乡村堕胎者实施,一例是因为性别选择,一例是未婚青春期少女的意外妊娠。由于隐瞒流产病史,未婚女性的处理更加复杂。

结论：这些不安全流产的报告强调指出：临床医生面对任何一个具有奇怪的腹部临床图像的育龄期女性时,都要都要高度怀疑是否隐瞒流产史。