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Pollie MP, Romanski PA, Bortoletto P, Spandorfer SD. Combining early pregnancy bleeding with ultrasound measurements to assess spontaneous abortion risk among infertile patients. Am J Obstet Gynecol 2023; 229:534.e1-534.e10. [PMID: 37487856 DOI: 10.1016/j.ajog.2023.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 07/04/2023] [Accepted: 07/16/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Approximately 15% of all clinically recognized pregnancies in patients with infertility result in spontaneous abortion. However, despite its potential to have a profound and lasting effect on physical and emotional well-being, the natural history of spontaneous abortion in women with infertility has not been described. Although vaginal bleeding is a common symptom in pregnancies conceived via reproductive technologies, its prognostic value is not well understood. OBJECTIVE This study aimed to evaluate the combination of early pregnancy bleeding and first-trimester ultrasound measurements to determine spontaneous abortion risk. STUDY DESIGN This was a retrospective cohort study of patients with infertility who underwent autologous embryo transfer resulting in singleton intrauterine pregnancy confirmed by ultrasound from January 1, 2017, to December 31, 2019. Early pregnancy symptoms of bleeding occurring before gestational week 8 and measurements of crown-rump length and fetal heart rate from ultrasounds performed during gestational week 6 (6 0/7 to 6 6/7 weeks of gestation) and gestational week 7 (7 0/7 to 7 6/7 weeks of gestation) were recorded. Modified Poisson regression with robust error variance was adjusted a priori for patient age, embryo transfer day, and transfer of a preimplantation genetic-tested embryo to estimate the relative risk and 95% confidence interval of spontaneous abortion for dichotomous variables. The relative risks and positive predictive values for early pregnancy bleeding combined with ultrasound measurements on the occurrence of spontaneous abortion were calculated for patients who had an ultrasound performed during gestational week 6 and separately for patients who had an ultrasound performed during gestational week 7. The primary outcome was spontaneous abortion in the setting of vaginal bleeding with normal ultrasound parameters. The secondary outcomes were spontaneous abortion with vaginal bleeding and (1) abnormal crown-rump length, (2) abnormal fetal heart rate, and (3) both abnormal crown-rump length and abnormal fetal heart rate. RESULTS Of the 1858 patients who were included (359 cases resulted in abortions and 1499 resulted in live births), 315 patients (17.0%) reported vaginal bleeding. When combined with ultrasound measurements from gestational week 6, bleeding was significantly associated with increased spontaneous abortion only when accompanied by absent fetal heart rate (relative risk, 5.36; 95% confidence interval, 3.36-8.55) or both absent fetal heart rate and absent fetal pole (relative risk, 9.67; 95% confidence interval, 7.45-12.56). Similarly, when combined with ultrasound measurements from gestational week 7, bleeding was significantly associated with increased spontaneous abortion only when accompanied by an abnormal assessment of fetal heart rate or crown-rump length (relative risk, 5.09; 95% confidence interval, 1.83-14.19) or both fetal heart rate and crown-rump length (relative risk, 14.82; 95% confidence interval, 10.54-20.83). With normal ultrasound measurements, bleeding was not associated with increased spontaneous abortion risk (relative risk: 1.05 [95% confidence interval, 0.61-1.78] in gestational week 6 and 0.80 [95% confidence interval, 0.36-1.74] in gestational week 7), and the live birth rate was comparable with that in patients with normal ultrasound measurements and no bleeding. CONCLUSION Patients with a history of infertility who present after embryo transfer with symptoms of vaginal bleeding should be evaluated with a pregnancy ultrasound to accurately assess spontaneous abortion risk. In the setting of normal ultrasound measurements, patients can be reassured that their risk of spontaneous abortion is not increased and that their live birth rate is not decreased.
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Affiliation(s)
| | - Phillip A Romanski
- Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, NY
| | - Pietro Bortoletto
- Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, NY
| | - Steven D Spandorfer
- Weill Cornell Medical College, Cornell University, New York, NY; Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, NY
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Idelson A, Meiri H, Wertheimer A, Sammar M, Tenenbaum-Gavish K, Shufaro Y, Ben-Haroush A. New predictors of early impaired placentation preceding miscarriage before 10 weeks of gestation in IVF pregnancies: A prospective study. Placenta 2020; 100:30-34. [PMID: 32814235 DOI: 10.1016/j.placenta.2020.07.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/26/2020] [Accepted: 07/30/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION In a recent study of 10,011 pregnant women, 95% of miscarriages occurred before routine ultrasound scan at 11-14 weeks. Our study aimed to identify early first trimester parameters which may predict miscarriage before 10 weeks of gestation for in vitro fertilization (IVF) pregnancies. METHODS A cohort of 115 healthy IVF patients with a singleton viable embryo in early first trimester were studied in a tertiary university-affiliated medical center (April 2017-June 2018). Calculations included gestational age (GA); ultrasound evaluation of crown-rump length (CRL), mean gestational sac diameter (GSD) and volume (GSV), mean yolk sac diameter (YSD) and volume (YSV); fetal heart rate (FHR), mean uterine arteries pulsatility index (UtA-PI); and maternal blood placental protein 13 (PP13) levels. Patients were divided into three groups by GA; and early miscarriage versus ongoing pregnancy after GA 10 weeks. RESULTS Early fetal loss occurred in 14.8% of patients; miscarriage group had higher discrepancy between calculated and measured GA (P < 0.001), lower GSD and GSV (P = 0.005 and P = 0.02, respectively), significantly different YSD and YSV, and lower GSD/YSD and GSV/YSV ratios (P = 0.001 and P = 0.003, respectively). UtA-PI/CRL ratio was higher in patients with miscarriage at GA 46-48 days and GA >48 days (P = 0.034 and P = 0.026, respectively). PP13/CRL ratio was higher in patients with miscarriage at GA >48 days (P = 0.041). DISCUSSION In IVF pregnancies with live embryo at first ultrasound scan, high UtA-PI/CRL and maternal blood PP13/CRL ratios may indicate impaired placentation preceded early pregnancy loss. A larger cohort is needed to further verify these predictions.
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Affiliation(s)
- Ana Idelson
- Obstetrics and Gynecology Ultrasound Unit, Helen Schneider Hospital for Women, Rabin Medical Center-Beilinson Hospital, Petach Tikva, 4941492, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel.
| | | | - Avital Wertheimer
- IVF and Infertility Unit, Helen Schneider Hospital for Women, Rabin Medical Center-Beilinson Hospital, Petach Tikva, 4941492, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel.
| | - Marei Sammar
- Ephraim Katzir Department of Biotechnology, ORT Braude College, Karmiel, 21982, Israel.
| | - Kineret Tenenbaum-Gavish
- Obstetrics and Gynecology Ultrasound Unit, Helen Schneider Hospital for Women, Rabin Medical Center-Beilinson Hospital, Petach Tikva, 4941492, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel.
| | - Yoel Shufaro
- IVF and Infertility Unit, Helen Schneider Hospital for Women, Rabin Medical Center-Beilinson Hospital, Petach Tikva, 4941492, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel.
| | - Avi Ben-Haroush
- IVF and Infertility Unit, Helen Schneider Hospital for Women, Rabin Medical Center-Beilinson Hospital, Petach Tikva, 4941492, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel.
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Detti L, Roman RA, Goedecke PJ, Christiansen ME, Peregrin-Alvarez I, Ikwuezunma G, Francillon L. Pilot study establishing a nomogram of yolk sac growth during the first trimester of pregnancy. J Obstet Gynaecol Res 2019; 46:223-228. [PMID: 31814235 DOI: 10.1111/jog.14173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 11/15/2019] [Indexed: 11/29/2022]
Abstract
AIM The yolk sac (YS) has been reported as a reliable predictor of adverse pregnancy outcomes, however, it has always been evaluated cross-sectionally with a single ultrasound per patient. We sought to validate the use of YS dimensions in serial ultrasounds throughout the first 10 weeks of singleton and multiple gestations. METHODS This was a prospective cohort study where YS diameters were serially obtained with 2D ultrasound in singleton and multiple gestations from 5 to 11 weeks. Nonparametric test were used for comparisons with P < 0.05 indicating significance. RESULTS One hundred ninety-three patients were included, 42 twins (3 monochorionic and 39 dichorionic), 2 triplets (monochorionic twins plus a singleton) and 148 singleton pregnancies (238 total fetuses). There was no difference in YS dimensions in singleton versus multiple pregnancies. Starting at 5 weeks' gestation, the YS increased 0.4 mm (95% CI 0.3-0.5 mm) per week until 10 weeks' gestation. Forty-five fetuses were lost in the first trimester. The risk of pregnancy loss was higher with a large YS until 8 weeks (P ≤ 0.001), while after 8 weeks it was higher with a small YS (P < 0.005). CONCLUSION We established a nomogram of YS development during the first 10 weeks of pregnancy. The YS reliably detected pregnancies that ended in loss as early as 6 weeks' gestation. The YS was either smaller or larger than in ongoing pregnancies. While all pregnancies with large YS were lost within 10 weeks, those with smaller YS were lost beyond the first 10 weeks.
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Affiliation(s)
- Laura Detti
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Robert A Roman
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Patricia J Goedecke
- Division of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Mary E Christiansen
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Irene Peregrin-Alvarez
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Gini Ikwuezunma
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Ludwig Francillon
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Riishede I, Berndt Wulff C, Kvist Ekelund C, Pinborg A, Tabor A. Risk of miscarriage in women conceiving after medically assisted reproduction with an ultrasound-verified viable pregnancy at 6-8 weeks' gestation. Reprod Biomed Online 2019; 39:819-826. [PMID: 31628037 DOI: 10.1016/j.rbmo.2019.06.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 06/17/2019] [Accepted: 06/21/2019] [Indexed: 11/16/2022]
Abstract
RESEARCH QUESTION What is the risk of miscarriage after a viable fetus verified on ultrasound at 6-8 weeks' gestation among women who conceive with medically assisted reproduction (MAR), stratified by type of fertility treatment? DESIGN A nationwide register-based cohort study of women identified in the Danish ART-Registry with a viable singleton pregnancy at 6-8 weeks' gestation between 2007 and 2010 (n = 10,011). Women were identified from The Danish Fetal Medicine Database (DFMD), which holds information on early (between 6-8 and 11-14 weeks) and late (between 11-14 and 22 weeks) miscarriages. The late miscarriage rate was compared with a control group of naturally conceived pregnancies with a viable fetus at 11-14 weeks' gestation from 2008 to 2010, identified in the DFMD (n = 146,932). RESULTS In the MAR1 cohort, the overall miscarriage rate was 11.8% (1091/9261) after an ultrasound verified viable pregnancy at 6-8 weeks' gestation. Most miscarriages occurred before the 11-14-week scan (1035/1091 [94.9%]). The early miscarriage rate was slightly higher in women who conceived with frozen embryo transfer compared with intrauterine insemination (IUI), corresponding to an adjusted OR of 1.31 (1.02 to 1.68). We found no significant risk associated with IVF and intracytoplasmic sperm injection compared with IUI pregnancies. The late miscarriage rate was 0.8% in women conceiving with MAR and 0.6% among controls (P = 0.013). CONCLUSIONS After adjustment for maternal characteristics, none of the fertility treatment types were associated with an increased risk of miscarriage compared with naturally conceiving women.
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Affiliation(s)
- Iben Riishede
- Center of Fetal Medicine, Department of Obstetrics, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark.
| | - Camilla Berndt Wulff
- Center of Fetal Medicine, Department of Obstetrics, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark; Faculty of Medicine and Health Sciences, University of Copenhagen, Blegdamsvej 3, Copenhagen 2200, Denmark
| | - Charlotte Kvist Ekelund
- Center of Fetal Medicine, Department of Obstetrics, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Anja Pinborg
- Faculty of Medicine and Health Sciences, University of Copenhagen, Blegdamsvej 3, Copenhagen 2200, Denmark; Fertility Clinic, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Ann Tabor
- Center of Fetal Medicine, Department of Obstetrics, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark; Faculty of Medicine and Health Sciences, University of Copenhagen, Blegdamsvej 3, Copenhagen 2200, Denmark
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Xiao S, Zhang H, Mo M, Hu X, Zeng Y, Hu L. Pregnancy and perinatal outcomes of first-trimester crown-rump length discordant IVF dichorionic twin pregnancies - a retrospective cohort study. Reprod Biomed Online 2019; 39:504-511. [PMID: 31362916 DOI: 10.1016/j.rbmo.2019.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 03/30/2019] [Accepted: 04/16/2019] [Indexed: 10/27/2022]
Abstract
RESEARCH QUESTION This study aimed to evaluate the association between discordance in crown-rump length (CRL) and adverse pregnancy and perinatal outcomes in dichorionic twin pregnancies. DESIGN This was a retrospective cohort study of dichorionic twin pregnancies after IVF that showed two live fetuses at the first ultrasound scan between 6 +5 and 8 weeks gestational age from 1 January 2015 to 31 December 2016. Study groups were defined by the presence or absence of 20% or more discordance in CRL. The primary outcomes were early fetal loss of one or both fetuses before 12 weeks and birthweight discordance. Secondary outcomes included fetal anomalies, fetal loss between 12 and 28 weeks, stillbirth, small for gestational age (SGA) at birth, low birthweight (LBW), very low birthweight (VLBW), admission to the neonatal intensive care unit (NICU) and preterm delivery (PTD). RESULTS CRL-discordant twin pregnancies were more likely to end in the loss of one fetus before 12 weeks' gestation (odds ratio [OR] 15.877, 95% confidence interval [CI] 10.495-24.019). Discordant twin pregnancies with twin deliveries had a significantly higher risk of birthweight discordance (OR 1.943, 95% CI 1.032-3.989). There was no significant difference in perinatal outcomes including fetal anomalies, PTD, LBW, VLBW, SGA, neonatal death and admission to NICU between singleton or twin deliveries. CONCLUSIONS Discordant twin pregnancies were at increased risk of one fetal loss prior to 12 weeks' gestation. Except for birthweight discordance, there was no significant difference between CRL discordance and other adverse perinatal outcomes.
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Affiliation(s)
- Shan Xiao
- Shenzhen Key Laboratory of Reproductive Immunology for Peri-implantation, Shenzhen Zhongshan Institute for Reproduction and Genetics, Fertility Center, Shenzhen Zhongshan Urology Hospital, Shenzhen, People's Republic of China
| | - Hongzhan Zhang
- Shenzhen Key Laboratory of Reproductive Immunology for Peri-implantation, Shenzhen Zhongshan Institute for Reproduction and Genetics, Fertility Center, Shenzhen Zhongshan Urology Hospital, Shenzhen, People's Republic of China; Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Chongqing Medical University Chongqing, People's Republic of China
| | - Meilan Mo
- Shenzhen Key Laboratory of Reproductive Immunology for Peri-implantation, Shenzhen Zhongshan Institute for Reproduction and Genetics, Fertility Center, Shenzhen Zhongshan Urology Hospital, Shenzhen, People's Republic of China
| | - Xiaodong Hu
- Shenzhen Key Laboratory of Reproductive Immunology for Peri-implantation, Shenzhen Zhongshan Institute for Reproduction and Genetics, Fertility Center, Shenzhen Zhongshan Urology Hospital, Shenzhen, People's Republic of China
| | - Yong Zeng
- Shenzhen Key Laboratory of Reproductive Immunology for Peri-implantation, Shenzhen Zhongshan Institute for Reproduction and Genetics, Fertility Center, Shenzhen Zhongshan Urology Hospital, Shenzhen, People's Republic of China.
| | - Lina Hu
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Chongqing Medical University Chongqing, People's Republic of China.
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Sabour S. Prediction of fetal loss by first-trimester crown-rump length in IVF pregnancies: prediction rules to avoid misinterpretation. Arch Gynecol Obstet 2017; 295:1297. [PMID: 28345110 DOI: 10.1007/s00404-017-4318-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 02/01/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Siamak Sabour
- Safety Promotion and Injury Prevention Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran. .,Department of Clinical Epidemiology, School of Health, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran.
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