Vaginal Bleeding in Late Pregnancy

Abnormal Uterine Bleeding: A Pictorial Review on Differential Diagnosis and Not-So-Common Cases of Interventional Radiology Management

Abnormal uterine bleeding (AUB) poses a multifaceted challenge in women's health, necessitating an integrated approach that addresses its diverse etiologies and clinical presentations. The International Federation of Gynecology and Obstetrics PALM-COEIN classification system provides a systematic approach to the diagnosis of AUB in non-pregnant women, based on clinical and imaging-based categorization of causes into structural (Polyps, Adenomyosis, Leiomyomas and Malignancy; PALM), and non-structural causes (Coagulopathies, Ovulatory disorders, primary Endometrial disorders, Iatrogenic and Not otherwise classified; COEIN). On the other hand, placental disorders, uterine rupture, ectopic pregnancy and retained products of conceptions are the main causes of uterine bleeding during pregnancy and in the peripartum period. Ultrasound is usually the first-line imaging technique for the differential diagnosis of causes of AUB. Computed Tomography may be useful if ultrasound findings are unclear, especially in emergency settings. Magnetic resonance imaging, when indicated, is an excellent second-line diagnostic tool for a better non-invasive characterization of the underlying cause of AUB. This pictorial review aims to illustrate the main causes of AUB from the point of view of diagnostic imaging and to show not-so-common cases that can be treated by means of interventional radiology.

Effect of Maternal Age and Body Mass Index on Induction of Labor Using Oral Misoprostol in Late-Term Pregnancies: A Retrospective Cross-Sectional Study

INTRODUCTION

Several studies have shown that late- and post-term pregnancies are associated with an increased risk of perinatal morbidity and mortality. In this case, induction of labor is the recommended approach. For full-term pregnancies, various methods exist to prepare the cervix and/or commence labor. Prostaglandins serve the dual purpose of cervical ripening and labor induction, blurring the distinction between the two processes. The aim of this research was to evaluate the effect of maternal age and body mass index (BMI) on oral misoprostol induction of labor for late-term pregnancies.

METHODS

This was a retrospective cross-sectional study (ClinicalTrial ID: NCT06184139), including only late-term pregnancies in healthy nulliparous women carrying a single cephalic fetus with normal birthweight who underwent induction of labor with oral misoprostol. We used the oral misoprostol regimen proposed by the World Health Organization (WHO) for induction of labor in term singleton pregnancies in women who have not had a previous cesarean delivery and a Bishop score <7. The regimen was oral misoprostol in aqueous solution at the low dose of 25 μg every 2 h until a Bishop score ≥7, labor, or for a maximum of 8 doses.

RESULTS

One hundred and four pregnant women underwent induction of labor with oral misoprostol for late-term pregnancy on the 290th day of gestation. Study population was divided in two groups based on age (<35 and ≥35 years) and obesity (BMI <30 and ≥30). No statistically significant differences were recorded between younger and older women. Obese women reported a longer time between the last dose of misoprostol and cervical dilation of 6 cm (p = 0.01), a longer time between the last dose of misoprostol and delivery (p = 0.04), and a higher rate of grade II vaginal lacerations (p = 0.02).

CONCLUSIONS

Maternal BMI is a factor negatively influencing the efficacy of oral misoprostol for induction of labor in late-term pregnancy.

Fetal Spina Bifida Repair in Obese Mothers: Is Maternal and Fetal Safety Compromised?

INTRODUCTION

The Management of Myelomeningocele Study (MOMS) eligibility criteria preclude in utero surgery for fetal spina bifida (fSB) when the maternal body mass index (BMI) is ≥35 kg/m2. Some centers still respect this criterion, while others, like ours, do not. This study aimed to assess whether maternal and fetal safety is compromised with higher maternal BMIs.

METHODS

Data of 192 patients with open fSB repair at our center were retrospectively analyzed. According to their BMI, patients were divided into three groups: group 1 (BMI <30 kg/m2), group 2 (BMI 30-35 kg/m2), and group 3 (BMI >35 kg/m2). Subgroup analysis was performed to assess differences in maternal and fetal outcomes. Additionally, complications were divided into grades 1 to 5 according to their severity and outcome consequences and compared among groups.

RESULTS

Out of 192 patients, 146 (76.0%) had a BMI <30 kg/m2, 28 (14.6%) had a BMI 30-35 kg/m2, and 18 (9.4%) had a BMI >35 kg/m2. Significant differences occurring more often in either group 2 or 3 compared to group 1 were maternal wound seroma (50% or 56% vs. 32%, p = 0.04), amniotic fluid leakage (14% or 6% vs. 2%, p = 0.01) as well as vaginal bleeding (11% or 35% vs. 9%, p = 0.01). On the contrary, duration of tocolysis with atosiban was shorter in patients with BMI >30 kg/m2 (4 or 5 vs. 6 days, p = 0.01). When comparing severity of maternal or fetal complications, grade 1 intervention-related complications occurred significantly more often in group 3 compared to group 1 or 2 (78% vs. 45% or 57%, p = 0.02). Gestational age at delivery was around 36 weeks in all groups without significant differences.

CONCLUSION

This investigation did not identify clinically relevant maternal and/or fetal outcome problems related to BMIs >35 kg/m2. Additional studies are however needed to confirm our results.

Colposcopy-A Valuable Diagnostic Tool for Pregnant Women With Unexplained Vaginal Bleeding

OBJECTIVES

We aimed to examine the diagnostic value of colposcopy in a large cohort of pregnant women with unexplained vaginal bleeding during the second or third trimester.

MATERIALS AND METHODS

This retrospective study included women who underwent colposcopy due to vaginal bleeding in the second and third trimesters during 2012-2022 at a tertiary care hospital. Demographics, obstetric data, bleeding characteristics, colposcopy results, cervical cytology testing, a sonogram directed at the placenta, and birth details were collected.

RESULTS

In total, 364 women were included. The mean maternal age was 29.7 years and the mean gestational age at examination was 30.7 weeks. Vaginal bleeding was mild in 80.8%, moderate in 14.6%, and severe in 4.7%. Only 3.3% had been vaccinated against human papilloma virus and 25.5% underwent a Pap smear study before pregnancy. Colposcopy diagnosed the bleeding source in 83 women (22.8%). The colposcopic examination revealed vaginal bleeding due to contact bleeding from ectropion in 46 (12.6%), a decidual/cervical polyp in 37 (10.2%), acetowhite epithelium in 12 (3.3%), herpes genetalis in 2 (0.5%), and bleeding from vaginal varices in 2 (0.5%). Of those who were recommended a follow-up examination after the postpartum period, only 49.1% completed such.Among women with compared to without postcoital bleeding ( N = 72), the risk of abnormal colposcopic findings was higher (24 [33.3%] vs 54 [19.7%], p = .017) and the rate of abnormal Pap smear was higher (7 [13.2%] vs 7 [3.2%], p = .008).

CONCLUSIONS

Colposcopy can be a valuable diagnostic tool for women with unexplained vaginal bleeding in the second or third trimester.

Gynaecological Causes of Acute Pelvic Pain: Common and Not-So-Common Imaging Findings

In female patients, acute pelvic pain can be caused by gynaecological, gastrointestinal, and urinary tract pathologies. Due to the variety of diagnostic possibilities, the correct assessment of these patients may be challenging. The most frequent gynaecological causes of acute pelvic pain in non-pregnant women are pelvic inflammatory disease, ruptured ovarian cysts, ovarian torsion, and degeneration or torsion of uterine leiomyomas. On the other hand, spontaneous abortion, ectopic pregnancy, and placental disorders are the most frequent gynaecological entities to cause acute pelvic pain in pregnant patients. Ultrasound (US) is usually the first-line diagnostic technique because of its sensitivity across most common aetiologies and its lack of radiation exposure. Computed tomography (CT) may be performed if ultrasound findings are equivocal or if a gynaecologic disease is not initially suspected. Magnetic resonance imaging (MRI) is an extremely useful second-line technique for further characterisation after US or CT. This pictorial review aims to review the spectrum of gynaecological entities that may manifest as acute pelvic pain in the emergency department and to describe the imaging findings of these gynaecological conditions obtained with different imaging techniques.

Desenlaces maternos según el tipo de placenta previa en un hospital de alta complejidad en Cali, Colombia. Estudio de cohorte retrospectivo

Objetivos: describir la frecuencia de complicaciones maternas en mujeres gestantes con placenta previa (PP) mayor o menor y evaluar una posible de asociación entre tipo de PP y la presencia de hemorragia materna severa y otros resultados maternos asociados. Materiales y métodos: cohorte retrospectiva, descriptiva. Se incluyeron gestantes con 20 semanas o más de embarazo, con diagnóstico confirmado de placenta previa, quienes fueron atendidas en un hospital de alto nivel de complejidad localizado en Cali (Colombia), entre enero de 2011 y diciembre de 2020. Se excluyeron las gestantes con diagnóstico de placenta previa y acretismo placentario concomitante. Las variables recolectadas fueron: edad materna, índice de masa corporal, tabaquismo, obesidad, paridad, presencia de sangrado, hemorragia posparto, manejo de la hemorragia posparto, transfusión y admisión a UCI de la gestante. Se realizó análisis descriptivo. El protocolo fue aprobado por el comité de ética de la Fundación Valle de Lili. Resultados: 146 pacientes cumplieron con los criterios de inclusión. La población estuvo constituida por mujeres con una mediana de edad de 32 años, sin antecedente quirúrgico, con diagnóstico prenatal de placenta previa a la semana 22. En el 70,5 % de los casos se trató de pacientes con placenta previa mayor. Las complicaciones más frecuentes fueron hemorragia posparto (37,9 % vs. 16,3 % para pacientes con placenta previa mayor y menor, respectivamente), requerimiento de transfusión (23,3 y 9,3 %, respectivamente) y el ingreso materno a la UCI (40,8 % vs. 18,6 %, respectivamente). No se registraron muertes maternas. Conclusiones: las mujeres con placenta previa experimentan una frecuencia elevada de complicaciones; probablemente, dicha frecuencia es más alta cuando se documenta placenta previa mayor. Se requieren más estudios que comparen la frecuencia de complicaciones maternas según el tipo de placenta previa.

Application of thromboelastography in diagnosing normal pregnancies and pregnancies with complications

Background

This observational study aimed to compare the potential application of thromboelastography (TEG) in diagnosing women with normal pregnancy (NP) and women with threatened abortion (TA), missed abortion (MA), embryo arrest (EA), fetal death (FD), history of abnormal pregnancy (HAP), and antiphospholipid antibody syndrome (AA).

Methods

According to the relevant clinical criteria, patients were divided into groups, and their blood samples were subjected to TEG. Next, the parameters R, K, α‐angle, MA, LY‐30, G, and coagulation index (CI) were analyzed. Partial correlation analysis was used to analyze correlation between groups of data. LSD‐t test and Dunnett's T3 test were used to analyze continuous variables. Ordinal categorical variables were compared using ordinal logistic regression analysis and estimate odds ratio of risk factors. A receiver operating characteristic (ROC) curve was constructed to detect the ability of TEG to recognize various parameters, and areas under the curve were compared using Delong's test for diagnosing pregnancy‐related diseases.

Results

MA had a negative effect on the MA parameter in TEG; EA had a negative effect on the MA and G parameters; HAP had a negative effect on the CI parameter and a positive effect on the R parameter; AA had a negative effect on the CI parameter. Compared with that of the NP group, the G of the EA (p = 0.014) group and the CI of the TA (p = 0.036) MA (p = 0.08) EA (p = 0.026) HAP (p = 0.000004) and AA (p = 0.002) groups were reduced. In the ordinal logistic regression analysis, compared with that of the NP group, the high R value of the HAP group accounted for more than that of the NP group (OR = 48.76, p = 0.001); the high K value of the AA group accounted for more than that of the NP group (OR = 17.00, p = 0.023); the angle value distributions of the TA and AA groups were different from that of the NP group (OR = 3.30, p = 0.039; OR = 0.14, p = 0.029); the low MA value of the MA, EA, and HAP groups accounted for more than that of the NP group (OR = 0.16, p = 0.03; OR = 0.26, p = 0.005; OR = 0.11, p = 0.008); and the low CI value of the HAP group accounted for more than that of the NP group (OR = 0.09, p = 0.005). In the ROC analysis, there were no significant differences in the TEG parameters of pregnant women belonging to the NP and TA, NP and MA, NP and EA, NP and FD, NP and HAP, and NP and AA groups (p > 0.05).

Maternal and Neonatal Outcomes Resulting from Antepartum Hemorrhage in Women with Placenta Previa and Its Associated Risk Factors: A Single-Center Retrospective Study

Purpose

Antepartum hemorrhage (APH) in women with placenta previa (PP) has been associated with increased perinatal complications. The present study aims to evaluate the maternal and neonatal outcomes, and risk factors related to this condition.

Methods

This retrospective study was conducted in the Obstetrics and Gynecology Department of the Second Affiliated Hospital of Army Military Medical University from January 2016 to September 2019, which included all women with PP. The clinical and ultrasound features in patients with or without APH were compared.

Results

There were 233 women with APH and 302 women without APH in the cohort. Most of the women with APH were prone to adverse maternal and neonatal outcomes. In the logistic regression analysis, cervical length was inversely correlated to APH (OR: 0.972, 95% CI: 0.952~0.993), while complete PP increased the risk for APH (OR: 2.121, 95% CI: 1.208~3.732). Furthermore, the anterior placenta increased the risk for APH (OR: 1.664, 95% CI: 1.139~2.430), the partial absence of the over lying myometrium increased the risk for APH (OR: 2.015, 95% CI: 1.293~3.141), and the previous history of uterine artery embolization (UAE) increased the highest risk for APH (OR: 11.706, 95% CI: 1.424~96.195).

Conclusion

Obstetricians should be aware of the increased risk of adverse pregnancy outcomes related to APH in women with complete PP, short cervical length, anterior placenta, and partially absent over lying myometrium. Prior UAE is a novel risk factor associated with increased prevalence of APH.