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Dudukina E, Horváth-Puhó E, Sørensen HT, Ehrenstein V. Association between vaginal bleeding in pregnancy that resulted in delivery and risk of cancer: A Danish registry-based cohort study. Paediatr Perinat Epidemiol 2024; 38:330-342. [PMID: 37580881 DOI: 10.1111/ppe.13001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 07/17/2023] [Accepted: 07/28/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Vaginal bleeding (VB) before 20 gestational weeks of a viable pregnancy is a manifestation of a threatened miscarriage. VB is associated with increased levels of pro-inflammatory cytokines such as interferon-gamma, tumour necrosis factor-alpha and interleukin-6. Increased levels of these cytokines and oxidative stress are risk factors for cancer. The risk of cancer following a VB-affected pregnancy that ended in childbirth is unknown. OBJECTIVES To investigate the associations between VB in pregnancy that resulted in delivery and risk of incident cancer. METHODS We conducted a cohort study (1995-2018) in Denmark using administrative and healthcare registries. We included 37,082 VB-affected deliveries, 1,363,614 VB-unaffected deliveries, 324,328 pregnancies ending in terminations, and 137,104 miscarriages. We computed the absolute risk of cancer and hazard ratios (HR) with 95% confidence intervals (CI) adjusted for age, calendar year, morbidities, and socio-economic factors using Cox proportional hazards regression. Multiple pregnancies to the same woman were accounted for in the analysis. RESULTS The median (25th-75th percentile) follow-up in the study was 12.6 (6.9, 18.2) years. The prevalence of VB in the present study was 3%. At the end of the follow-up, there were 1320 cancer cases among the VB-affected delivery cohort, 40,420 among the VB-unaffected delivery cohort, 10,300 among the termination cohort and 4790 among the miscarriage cohort. HRs for any cancer among VB-affected deliveries were 1.03 (95% CI 0.97, 1.08) compared with VB-unaffected deliveries, 1.03 (95% CI 0.97, 1.09) compared with terminations and 0.90 (95% CI 0.84, 0.95) compared with miscarriages. There were no increased risks of premenopausal breast cancer, cervical cancer, ovary and fallopian tube cancer or uterine cancer following VB-affected deliveries vs. comparison cohorts. CONCLUSIONS We found no evidence of an association between vaginal bleeding in pregnancy and an increased risk of cancer.
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Affiliation(s)
- Elena Dudukina
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Erzsébet Horváth-Puhó
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Vera Ehrenstein
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
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Dudukina E, Horváth-Puhó E, Sørensen HT, Ehrenstein V. Association between pregnancy affected by vaginal bleeding and women's mortality: A cohort study. BJOG 2024; 131:175-188. [PMID: 37519289 DOI: 10.1111/1471-0528.17623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 07/10/2023] [Accepted: 07/12/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE To investigate the association between vaginal bleeding (VB) in pregnancy and women's mortality, using VB-unaffected pregnancies, terminations and miscarriages as comparators. DESIGN Observational cohort study. SETTING Nationwide registries of Denmark linked at an individual level. POPULATION OR SAMPLE 1 354 181 women and their 3 162 317 pregnancies (1979-2017), including 70 835 VB-affected pregnancies and comparators: 2 236 359 VB-unaffected pregnancies ending in childbirth; 589 697 terminations; and 265 426 miscarriages. METHODS We followed pregnancies until the earliest date of woman's death, emigration or end of data. MAIN OUTCOME MEASURES All-cause and cause-specific mortality rates per 10 000 person-years (PY) and hazard ratios (HRs) with 95% confidence intervals (CIs) adjusted using Cox proportional hazards regression for age, calendar year, pre-existing chronic conditions and socio-economic factors. RESULTS There were 2320 deaths from any cause among women following VB-affected pregnancy (mortality rate 15.2, 95% CI 14.6-15.9 per 10 000 PY); 55 030 deaths following VB-unaffected pregnancy (mortality rate 12.7, 95% CI 12.6-12.8); 27 500 deaths following a termination (mortality rate 21.9, 95% CI 21.6-22.1), and 10 865 deaths following a miscarriage (mortality rate 19.2, 95% CI 18.8-19.6). For comparison of VB-affected versus VB-unaffected pregnancies, associations with all-cause (HR 1.14, 95% CI 1.09-1.19), natural causes (HR 1.15, 95% CI 1.09-1.22) and non-natural causes (HR 1.27, 95% CI 1.08-1.48) mortality were attenuated in a sensitivity analysis of pregnancies recorded in 1994-2017 (HR 1.00, 95% CI 0.90-1.12, HR 0.98, 95% CI 0.85-1.14 and HR 1.04, 95% CI 0.72-1.51, respectively). Contrasts with remaining comparators did not suggest increased risks of all-cause, natural or non-natural mortality causes. CONCLUSION We found no evidence of an increased risk of women's mortality following VB-affected versus VB-unaffected pregnancy, termination or miscarriage.
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Affiliation(s)
- Elena Dudukina
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Erzsébet Horváth-Puhó
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Vera Ehrenstein
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
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Dudukina E, Horváth-Puhó E, Sørensen HT, Ehrenstein V. Risk of diabetes and cardiovascular diseases in women with vaginal bleeding before 20 gestational weeks: Danish population-based cohort study. Int J Epidemiol 2023; 52:1783-1794. [PMID: 37758298 DOI: 10.1093/ije/dyad130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 09/15/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Women's reproductive health is associated with cardiovascular morbidity. However, an association of vaginal bleeding (VB) in pregnancy with diabetes and cardiovascular outcomes has scarcely been investigated. METHODS We conducted a population-based cohort study in Denmark (1994-2018). Using nationwide registries, among 903 327 women we identified 1 901 725 pregnancies: 39 265 ended in childbirth and were affected by VB; 1 389 285 ended in childbirth and were unaffected by VB; 333 785 ended in a termination, and 139 390 ended in a miscarriage. The outcomes were diabetes types 1 and 2, hypertension, ischaemic heart disease including myocardial infarction, atrial fibrillation or flutter, heart failure and ischaemic and haemorrhagic stroke. We computed incidence rates and hazard ratios (HRs) with 95% confidence intervals (CIs) adjusted for age, calendar year of pregnancy end, morbidities and reproductive and socioeconomic factors, using inverse probability of treatment-weighted Cox proportional hazards regression. RESULTS In analyses of VB-affected vs VB-unaffected pregnancies, aHRs were 1.15 (1.03-1.28) for diabetes type 1, 1.19 (1.13-1.26) for diabetes type 2, 1.19 (1.14-1.25) for hypertension, 1.26 (1.16-1.37) for ischaemic heart disease, 1.21 (1.03-1.42) for myocardial infarction, 1.32 (1.14-1.51) for atrial fibrillation or flutter and 1.23 (0.99-1.52) for heart failure. aHRs were 1.41 (1.26-1.57) and 1.46 (1.23-1.72) for ischaemic and haemorrhagic stroke, respectively. When contrasting VB-affected pregnancies with terminations, aHRs were up to 1.3-fold increased for diabetes and hypertension; however, when contrasting VB-affected pregnancies with miscarriages, estimates were below or close to the null value. CONCLUSIONS Women's risks of diabetes and cardiovascular outcomes later in life were increased following VB-affected vs VB-unaffected pregnancy or termination, but not following VB-affected pregnancy vs miscarriage.
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Affiliation(s)
- Elena Dudukina
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Erzsébet Horváth-Puhó
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Vera Ehrenstein
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
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Elmas B, Özgü BS, Zorlu U, Koç BL, Ozdemir EU, Akkaya SK, Akay A, Öztürk N, Erkaya S. Do First-Trimester Subchorionic Hematomas Affect Pregnancy Outcomes? Z Geburtshilfe Neonatol 2023; 227:31-35. [PMID: 36170877 DOI: 10.1055/a-1929-9500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVE The aim of this study is to investigate the relationship between first trimester subchorionic hematomas and pregnancy outcomes in women with singleton pregnancies. MATERIAL AND METHODS Between January 2018 and January 2019, patients who had a single pregnancy between the 6th and 14th weeks of their pregnancy and were hospitalized with the diagnosis of abortus imminens in the early pregnancy service were included in the study. According to the ultrasonographic examination, those with subchorionic hematoma and those with no hematoma were compared in terms of demographic data, pregnancy outcomes and pregnancy complications. RESULTS 400 abortus immines cases with subchorionic hematoma and 400 abortus imminens cases without subchorionic hematoma were compared. Preterm delivery percentages were similar in both groups, however abortus percentage was significantly higher in the hematoma group (34.2 vs. 24.7%; p=0.007). In addition, it was revealed that the presence of subchorionic hematoma before the 20th gestational week increased the risk of miscarriage 1.58 times. However, no data could be found in the study that could correlate the size of the hematoma with pregnancy loss. CONCLUSION The presence of subchorionic hematoma increases abortion rates in abortus imminens cases. And the presence of subchorionic hematoma in cases with ongoing pregnancy does not increase the complications of delivery.
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Affiliation(s)
- Burak Elmas
- Department of Gynecology and Obstetrics, Ankara Şehir Hastanesi, Cankaya, Turkey
| | - Burçin Salman Özgü
- Department of Gynecology and Obstetrics, Ankara Şehir Hastanesi, Cankaya, Turkey
| | - Uğurcan Zorlu
- Department of Gynecology and Obstetrics, Ankara Şehir Hastanesi, Cankaya, Turkey
| | - Bergen Laleli Koç
- Department of Gynecology and Obstetrics, Ankara Şehir Hastanesi, Cankaya, Turkey
| | - Eda Ureyen Ozdemir
- Department of Gynecology and Obstetrics, Ankara Şehir Hastanesi, Cankaya, Turkey
| | - Selver Kübra Akkaya
- Department of Gynecology and Obstetrics, Ankara Şehir Hastanesi, Cankaya, Turkey
| | - Arife Akay
- Department of Gynecology and Obstetrics, Ankara Etlik Zübeyde Hanım Kadın Hastalıkları Eğitim ve Araştırma Hastanesi, Ankara, Turkey
| | - Neslihan Öztürk
- Department of Gynecology and Obstetrics, Kırıkkale yüksek ihtisas hastanesi, Kırıkkale, Turkey
| | - Salim Erkaya
- Department of Gynecology and Obstetrics, Ankara Etlik Zübeyde Hanım Kadın Hastalıkları Eğitim ve Araştırma Hastanesi, Ankara, Turkey
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Ku CW, Ong LS, Goh JP, Allen J, Low LW, Zhou J, Tan TC, Lee YH. Defects in protective cytokine profiles in spontaneous miscarriage in the first trimester. F&S SCIENCE 2023; 4:36-46. [PMID: 36096448 DOI: 10.1016/j.xfss.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 09/04/2022] [Accepted: 09/06/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To study differences in cytokine expression profiles between women with ongoing pregnancy and those experiencing spontaneous miscarriage, among women who presented with threatened miscarriage before week 16 of gestation. DESIGN Prospective cohort study. SETTING Academic hospital. PATIENT(S) In this prospective cohort study, 155 pregnant women, comprising normal pregnant women recruited from antenatal clinics (n = 97) and women with threatened miscarriage recruited from an emergency walk-in clinic (n = 58). INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Sixty-five serum cytokines quantified using multiplex immunoassay correlated with miscarriage outcomes. RESULT(S) Among women presenting with threatened miscarriage, those who eventually miscarried had significantly lower levels of interleukin (IL)-2, IL-12p70, IL-17A, B-cell-activating factor, B lymphocyte chemoattractant, basic nerve growth factor, interferon-γ, tumor necrosis factor-related apoptosis-inducing ligand, thymic stromal lymphopoietin, and tumor necrosis factor-α and higher levels of vascular endothelial growth factor A, IL-21, and stromal cell-derived factor 1α than those with ongoing pregnancy. Comparisons between normal pregnancies and women with threatened miscarriage who eventually miscarried revealed significant differences across 7 cytokines: B-cell-activating factor; B lymphocyte chemoattractant; basic nerve growth factor; IL-17A; fractalkine/CX3CL1; vascular endothelial growth factor A; and CCL22. Vascular endothelial growth factor A exhibited a negative correlation with the progesterone level (r = -0.270). The cluster of significant cytokines alludes to T cell proliferation, B-cell proliferation, natural killer cell-mediated cytotoxicity, and apoptosis as important pathways that determine pregnancy outcomes. Bioinformatic analysis further revealed alteration of the suppressor of cytokine signaling proteins family of Janus kinase-signal transducer and activator of transcription signaling axis by cytokines as a plausible key molecular mechanism in spontaneous miscarriage. CONCLUSION(S) This study demonstrates that the regulated balance between the proinflammatory and anti-inflammatory pathways is crucial to maintaining pregnancy. A better understanding of the cytokines associated with immunomodulatory effects may lead to novel targets for the prediction and treatment of spontaneous miscarriage.
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Affiliation(s)
- Chee Wai Ku
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore; Duke-NUS Medical School, Singapore
| | | | - Jody Paige Goh
- Division of Obstetrics and Gynecology, KK Women's and Children's Hospital, Singapore
| | | | - Louise Wenyi Low
- Division of Obstetrics and Gynecology, KK Women's and Children's Hospital, Singapore; Obstetrics and Gynecology-Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Jieliang Zhou
- Division of Obstetrics and Gynecology, KK Women's and Children's Hospital, Singapore; Obstetrics and Gynecology-Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Thiam Chye Tan
- Division of Obstetrics and Gynecology, KK Women's and Children's Hospital, Singapore; Obstetrics and Gynecology-Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Yie Hou Lee
- Obstetrics and Gynecology-Academic Clinical Program, Duke-NUS Medical School, Singapore; Translational 'Omics and Biomarkers Group, KK Research Centre, KK Women's and Children's Hospital, Singapore.
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Linde LE, Rasmussen S, Moster D, Kessler J, Baghestan E, Gissler M, Ebbing C. Risk factors and recurrence of cause-specific postpartum hemorrhage: A population-based study. PLoS One 2022; 17:e0275879. [PMID: 36240210 PMCID: PMC9565392 DOI: 10.1371/journal.pone.0275879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/23/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To explore risk profiles of the different types of postpartum hemorrhage (PPH >500ml or severe PPH >1500ml) and their recurrence risks in a subsequent delivery. METHODS With data from The Medical Birth Registry of Norway and Statistics Norway we performed a population-based cohort study including all singleton deliveries in Norway from 1967-2017. Multilevel logistic regression was used to calculate odds ratio (OR), with 95% confidence interval (CI), with different PPH types (PPH >500ml or PPH >1500ml (severe PPH) combined with retained placenta, uterine atony, obstetric trauma, dystocia, or undefined cause) as outcomes. RESULT We identified 277 746 PPH cases of a total of 3 003 025 births (9.3%) from 1967 to 2017. Retained placenta (and/or membranes) was most often registered as severe PPH (29.3%). Maternal, fetal, and obstetric characteristics showed different associations with the PPH types. Male sex of the neonate was associated with reduced risk of PPH. This effect was strongest on PPH due to retained placenta (adjusted OR, (aOR): 0.80, 95% CI 0.78-0.82), atony (aOR 0.92, 95% CI: 0.90-0.93) and PPH with undefined cause (aOR 0.96, 95% CI: 0.95-0.97). Previous cesarean section showed a strong association with PPH due to dystocia (aOR of 13.2, 95% CI: 12.5-13.9). Recurrence risks were highest for the same type: PPH associated with dystocia (aOR: 6.8, 95% CI: 6.3-7.4), retained placenta and/or membranes (aOR: 5.9, 95% CI: 5.5-6.4), atony (aOR: 4.0, 95% CI: 3.8-4.2), obstetric trauma (aOR: 3.9, 95% CI: 3.5-4.3) and PPH of undefined cause (aOR: 2.2, 95% CI: 2.1-2.3). CONCLUSION Maternal, fetal and obstetric characteristics had differential effects on types of PPH. Recurrence differed considerably between PPH types. Retained placenta was most frequently registered with severe PPH, and showed strongest effect of sex; delivery of a boy was associated with lower risk of PPH. Previous cesarean increased the risk of PPH due to dystocia.
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Affiliation(s)
| | - Svein Rasmussen
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Dag Moster
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Jörg Kessler
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway
| | - Elham Baghestan
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway
| | - Mika Gissler
- Finnish Institute for Health and Welfare, Department of Knowledge Brokers, Helsinki, Finland
- Karolinska Institute, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | - Cathrine Ebbing
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway
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Comparison of Obstetric and Neonatal Results and Subchorionic Hematoma Area Effects of Pregnant Women with Abortus Imminence and Healthy Pregnant Women. ANADOLU KLINIĞI TIP BILIMLERI DERGISI 2021. [DOI: 10.21673/anadoluklin.861511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Dudukina E, Horváth-Puhó E, Sørensen HT, Ehrenstein V. Long-term risk of epilepsy, cerebral palsy and attention-deficit/hyperactivity disorder in children affected by a threatened abortion in utero. Int J Epidemiol 2021; 50:1540-1553. [PMID: 33846731 DOI: 10.1093/ije/dyab069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 03/15/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The birth of a child affected by a threatened abortion (TAB) in utero is associated with autism spectrum disorder; association with other neurological disorders is unknown. METHODS This nationwide registry-based cohort study included singletons live-born in Denmark (1979-2010), followed through 2016. The outcomes were epilepsy, cerebral palsy (CP) and attention-deficit/hyperactivity disorder (ADHD). We used Cox regression to compute hazard ratios (HRs), adjusted for birth year, birth order, parental age, morbidity, medication use and maternal socio-economic factors. To remove time-invariant family-shared confounding, we applied sibling analyses. RESULTS The study population included 1 864 221 singletons live-born in 1979-2010. Among the TAB-affected children (N = 59 134) vs TAB-unaffected children, at the end of follow-up, the cumulative incidence was 2.2% vs 1.6% for epilepsy, 0.4% vs 0.2% for CP and 5.5% vs 4.2% for ADHD (for children born in 1995-2010). The adjusted HRs were 1.25 [95% confidence interval (CI) 1.16-1.34] for epilepsy, 1.42 (95% CI 1.20-1.68) for CP and 1.21 (95% CI 1.14-1.29) for ADHD. In the sibling design, the adjusted HRs were unity for epilepsy (full siblings: 0.96, 95% CI 0.82-1.12; maternal: 1.04, 95% CI 0.90-1.20; paternal: 1.08, 95% CI 0.93-1.25) and ADHD (full: 1.08, 95% CI 0.92-1.27; maternal: 1.04, 95% CI 0.90-1.20; paternal: 1.08, 95% CI 0.93-1.25). For CP, HRs shifted away from unity among sibling pairs (full: 2.92, 95% CI 1.33-6.39; maternal: 2.03, 95% CI 1.15-3.57; paternal: 3.28, 95% CI 1.36-7.91). CONCLUSIONS The birth of a child affected by TAB in utero was associated with a greater risk of CP, but not epilepsy or ADHD.
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Affiliation(s)
- Elena Dudukina
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | | | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Vera Ehrenstein
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
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Liu S, Yu L, Wu Q, Cui H, Lin X, Wang W. Study on the correlation between vaginal bleeding in first trimester and preterm birth: A birth cohort study in Lanzhou, China. J Obstet Gynaecol Res 2021; 47:1997-2004. [PMID: 33749042 DOI: 10.1111/jog.14750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 01/08/2021] [Accepted: 03/05/2021] [Indexed: 11/27/2022]
Abstract
OBJECTS To investigate the correlation between first trimester vaginal bleeding and preterm birth (PB), and to offer suggestions on the perinatal health care and preterm birth prevention. METHODS A birth cohort study was conducted on 10 179 pregnant women. Unconditional logistic regression model was used to evaluate the associations between vaginal bleeding and preterm birth in sub-preterm groups. RESULTS Of the 10 179 pregnant women included, a total of 1001 women suffered from vaginal bleeding during the first trimester, of which 119 suffered from PB. Any vaginal bleeding increased the risk of PB. Severe bleeding was a high-risk factor of PB, associated with 4.8-fold risk of very PB, 2.7-fold risk of spontaneous PB without PROM (premature rupture of membrane) and 4.6-fold risk of medical induced PB. Bleeding prolonged more than 1 week increased 66% risk of PB and 36% risk of PB on initial episode happened in 5-12 weeks of gestation age, especially in moderate PB, in medical-induced PB and in spontaneous PB with PPROM (preterm premature rupture of membrane which is one cause of PB). Mild bleeding or bleeding within 1 week or initial episode happened within 4 weeks of gestation age possibly had no influence on PB. CONCLUSION Vaginal bleeding in the first-trimester was an independent risk factor for PB. The severity, duration and initial time of vaginal bleeding had different effects on different subtypes of PB.
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Affiliation(s)
- Sufen Liu
- Aviation General Hospital, Beijing, China
| | - Liqun Yu
- Aviation General Hospital, Beijing, China
| | | | - Hongmei Cui
- Gansu Provincial Maternity & Child Care Hospital, Lanzhou, China
| | - Xiaojuan Lin
- Gansu Provincial Maternity & Child Care Hospital, Lanzhou, China
| | - Wendi Wang
- Gansu Provincial Maternity & Child Care Hospital, Lanzhou, China
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MPA given orally during the first trimester for threatened miscarriage carries no specific risk for foetal abnormalities albeit the rate is higher than non-threatened pregnancies. Reprod Biol 2020; 20:424-432. [PMID: 32389607 DOI: 10.1016/j.repbio.2020.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 03/12/2020] [Accepted: 03/14/2020] [Indexed: 11/21/2022]
Abstract
This observational study examines the outcomes of pregnancies arising in women referred for infertility, where those who experienced threatened miscarriage were treated with medroxyprogesterone acetate (MPA) tablets. The 14-year study period covers comprehensive real-time data entries into the validated electronic database including details of the infertility management, pregnancy outcomes and any foetal anomalies among the infants, each being tracked and recorded. Of 4057 clinical pregnancies, 1343 received MPA for threatened miscarriage; 934 (69.6 %) of which continued to livebirths. These were compared with the remaining 2714 clinical pregnancies without threatened miscarriage or MPA and which resulted in 2075 (76.5 %) livebirths. There were 134 developmental abnormalities recorded among the 3009 livebirths of which 78 (2.6 %) were categorised appropriate for the Western Australian Developmental Abnormalities Register; WARDA. These comprised 55 in the MPA group, 36 of which were categorised as serious (being 2.7 % of clinical pregnancies and 3.9 % of births). In the group without MPA, there were 79 abnormalities, of which 42 were categorised as serious (being 1.7 % of clinical pregnancies and 2.2 % of births). Specifically, there were no cases of androgenisation noted among the female infants. The abnormality rates were low overall and well within the annual WARDA ranges. We cautiously suggest that oral MPA can be considered for studies throughout pregnancy including the early first trimester to assess a potential role in reducing miscarriage, as well as advanced pregnancies to evaluate a potential role in reducing stillbirths and preterm delivery.
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Al-Memar M, Vaulet T, Fourie H, Nikolic G, Bobdiwala S, Saso S, Farren J, Pipi M, Van Calster B, de Moor B, Stalder C, Bennett P, Timmerman D, Bourne T. Early-pregnancy events and subsequent antenatal, delivery and neonatal outcomes: prospective cohort study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:530-537. [PMID: 30887596 DOI: 10.1002/uog.20262] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/28/2019] [Accepted: 02/28/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To assess prospectively the association between pelvic pain, vaginal bleeding, and nausea and vomiting occurring in the first trimester of pregnancy and the incidence of later adverse pregnancy outcomes. METHODS This was a prospective observational cohort study of consecutive women with confirmed intrauterine singleton pregnancy between 5 and 14 weeks' gestation recruited at Queen Charlotte's & Chelsea Hospital, London, UK, from March 2014 to March 2016. Serial ultrasound scans were performed in the first trimester. Participants completed validated symptom scores for vaginal bleeding, pelvic pain, and nausea and vomiting. The key symptom of interest was any pelvic pain and/or vaginal bleeding during the first trimester. Pregnancies were followed up until the final outcome was known. Antenatal, delivery and neonatal outcomes were obtained from hospital records. Logistic regression analysis was used to assess the association between first-trimester symptoms and pregnancy complications by calculating adjusted odds ratios (aOR) with correction for maternal age. RESULTS Of 1003 women recruited, 847 pregnancies were included in the final analysis following exclusion of cases due to first-trimester miscarriage (n = 99), termination of pregnancy (n = 20), loss to follow-up (n = 32) or withdrawal from the study (n = 5). Adverse antenatal complications were observed in 166/645 (26%) women with pelvic pain and/or vaginal bleeding in the first trimester (aOR = 1.79; 95% CI, 1.17-2.76) and in 30/181 (17%) women with no symptoms. Neonatal complications were observed in 66/634 (10%) women with and 11/176 (6%) without pelvic pain and/or vaginal bleeding (aOR = 1.73; 95% CI, 0.89-3.36). Delivery complications were observed in 402/615 (65%) women with and 110/174 (63%) without pelvic pain and/or vaginal bleeding during the first trimester (aOR = 1.16; 95% CI, 0.81-1.65). For 18 of 20 individual antenatal complications evaluated, incidence was higher among women with pelvic pain and/or vaginal bleeding, despite the overall incidences being low. Nausea and vomiting in pregnancy showed little association with adverse pregnancy outcomes. CONCLUSIONS Our study suggests that there is an increased incidence of antenatal complications in women experiencing pelvic pain and/or vaginal bleeding in the first trimester. This should be considered when advising women attending early-pregnancy units. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M Al-Memar
- Tommy's National Early Miscarriage Research Centre, Queen Charlotte's & Chelsea Hospital, Imperial College London, London, UK
| | - T Vaulet
- ESAT-STADIUS, Stadius Centre for Dynamical Systems, Signal Processing and Data Analytics, Leuven, Belgium
- Imec, Leuven, Belgium
| | - H Fourie
- Tommy's National Early Miscarriage Research Centre, Queen Charlotte's & Chelsea Hospital, Imperial College London, London, UK
| | - G Nikolic
- ESAT-STADIUS, Stadius Centre for Dynamical Systems, Signal Processing and Data Analytics, Leuven, Belgium
- Imec, Leuven, Belgium
| | - S Bobdiwala
- Tommy's National Early Miscarriage Research Centre, Queen Charlotte's & Chelsea Hospital, Imperial College London, London, UK
| | - S Saso
- Tommy's National Early Miscarriage Research Centre, Queen Charlotte's & Chelsea Hospital, Imperial College London, London, UK
| | - J Farren
- Tommy's National Early Miscarriage Research Centre, Queen Charlotte's & Chelsea Hospital, Imperial College London, London, UK
| | - M Pipi
- Tommy's National Early Miscarriage Research Centre, Queen Charlotte's & Chelsea Hospital, Imperial College London, London, UK
| | - B Van Calster
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Biomedical Data Sciences, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | - B de Moor
- ESAT-STADIUS, Stadius Centre for Dynamical Systems, Signal Processing and Data Analytics, Leuven, Belgium
- Imec, Leuven, Belgium
| | - C Stalder
- Tommy's National Early Miscarriage Research Centre, Queen Charlotte's & Chelsea Hospital, Imperial College London, London, UK
| | - P Bennett
- Tommy's National Early Miscarriage Research Centre, Queen Charlotte's & Chelsea Hospital, Imperial College London, London, UK
| | - D Timmerman
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - T Bourne
- Tommy's National Early Miscarriage Research Centre, Queen Charlotte's & Chelsea Hospital, Imperial College London, London, UK
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
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Wilson RD, Gagnon A, Audibert F, Campagnolo C, Carroll J. Interventions et techniques de diagnostic prénatal visant l'obtention d'un prélèvement fœtal à des fins diagnostiques : Risques et avantages pour la mère et le fœtus. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 38:S688-S703. [PMID: 28063574 DOI: 10.1016/j.jogc.2016.09.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIF Offrir aux fournisseurs de soins de maternité et à leurs patientes des lignes directrices factuelles contemporaines en ce qui concerne les services de counseling traitant des risques et des avantages maternels propres à la tenue des interventions diagnostiques prénatales orientées par échographie (et/ou des techniques permettant l'établissement d'un diagnostic génétique) nécessaires dans les cas où il a été établi pendant la période prénatale que la grossesse serait exposée à des risques, ainsi qu'en ce qui concerne la prise de décisions subséquentes quant à la prise en charge de la grossesse (questions abordant des aspects tels que le niveau du fournisseur de soins obstétricaux, la surveillance prénatale, le lieu où devraient se dérouler les soins et l'accouchement, et la décision de poursuivre ou d'interrompre la grossesse). La présente directive clinique se limite aux services de counseling traitant des risques et des avantages maternels, et aux décisions en matière de prise en charge de la grossesse pour les femmes qui nécessitent (ou qui envisagent) la mise en œuvre d'une intervention ou d'une technique effractive orientée par échographie aux fins de l'établissement d'un diagnostic prénatal. POPULATION DE PATIENTES Femmes enceintes identifiées, à la suite de la mise en œuvre de protocoles établis de dépistage prénatal (taux sériques maternels ± imagerie, résultats d'analyse de l'ADN acellulaire indiquant des risques élevés, résultats anormaux au moment de l'imagerie fœtale diagnostique ou antécédents familiaux de troubles héréditaires), comme étant exposées à un risque accru d'anomalie génétique fœtale. Ces femmes pourraient nécessiter ou demander des services de counseling au sujet des risques et des avantages pour la grossesse de la tenue d'une intervention effractive orientée par échographie visant à déterminer l'étiologie, le diagnostic, et/ou la pathologie de possibles anomalies fœtales. RéSULTATS: La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans Medline, PubMed et The Cochrane Library jusqu'en juin 2014 au moyen d'un vocabulaire contrôlé (« prenatal diagnosis », « amniocentesis », « chorionic villi sampling », « cordocentesis ») et de mots clés (« prenatal screening », « prenatal genetic counselling », « post-procedural pregnancy loss rate ») appropriés. Les résultats ont été restreints aux analyses systématiques, aux études observationnelles et aux essais comparatifs randomisés / essais cliniques comparatifs publiés en anglais entre janvier 1985 et juin 2014. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en juin 2014. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. VALEURS La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau 1). AVANTAGES, DéSAVANTAGES ET COûTS: Consentement éclairé de la patiente, transfert des connaissances, évaluation du risque génétique prénatal, soulagement de l'anxiété, création d'anxiété, défense des droits, compréhension du dépistage fœtal, limites du dépistage fœtal, choix en matière de prise en charge de la grossesse, complication de la grossesse ou fausse couche, soins opportuns et améliorés pour l'accouchement d'un enfant présentant une morbidité reconnue. RECOMMANDATIONS.
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First-trimester bleeding and twin pregnancy outcomes after in vitro fertilization. Fertil Steril 2016; 106:140-143. [PMID: 27060729 DOI: 10.1016/j.fertnstert.2016.03.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 03/03/2016] [Accepted: 03/14/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To examine the association between first-trimester bleeding and live-birth rates in twin pregnancies conceived with in vitro fertilization (IVF). DESIGN Retrospective cohort study. SETTING Academic infertility practice. PATIENT(S) Women with two gestational sacs on first-trimester ultrasound after transfer of fresh embryos derived from autologous oocytes between January 1, 1999, and December 31, 2010. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Live-birth rate. RESULT(S) Sixty-five women reported vaginal bleeding, and 288 did not. The baseline characteristics were similar between the two groups, except for an increased prevalence of subchorionic hematoma in women with first-trimester vaginal bleeding (26.2% vs. 1.7%). Live-birth rates were similar between women with bleeding and those with no bleeding (87.7% vs. 91.7%, adjusted odds ratio [OR] 0.73; 95% confidence interval [CI], 0.31-1.73). Two hundred eighty-eight women gave birth to live twins. Among the women who delivered twins, those with first-trimester bleeding had an increased risk of low birth weight of at least one twin (75.0% vs. 59.7%). The association between bleeding and low birth weight persisted after controlling for possible confounders with logistic regression (adjusted OR 2.33, 95% CI, 1.14-4.74). CONCLUSION(S) Live-birth rates are high in IVF twin gestations, regardless of the presence of first-trimester bleeding. Among women giving birth to IVF twins, however, first-trimester bleeding is associated with increased odds of low birth weight.
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Ayorinde AA, Wilde K, Lemon J, Campbell D, Bhattacharya S. Data Resource Profile: The Aberdeen Maternity and Neonatal Databank (AMND). Int J Epidemiol 2016; 45:389-94. [PMID: 26800750 DOI: 10.1093/ije/dyv356] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2015] [Indexed: 11/13/2022] Open
Affiliation(s)
- Abimbola A Ayorinde
- Aberdeen Maternity and Neonatal Databank, Dugald Baird Centre for Research on Women's Health, Aberdeen Maternity Hospital, Aberdeen, UK and
| | - Katie Wilde
- Research Applications and Data Management Team, University of Aberdeen, Aberdeen, UK
| | - John Lemon
- Aberdeen Maternity and Neonatal Databank, Dugald Baird Centre for Research on Women's Health, Aberdeen Maternity Hospital, Aberdeen, UK and
| | - Doris Campbell
- Aberdeen Maternity and Neonatal Databank, Dugald Baird Centre for Research on Women's Health, Aberdeen Maternity Hospital, Aberdeen, UK and
| | - Sohinee Bhattacharya
- Aberdeen Maternity and Neonatal Databank, Dugald Baird Centre for Research on Women's Health, Aberdeen Maternity Hospital, Aberdeen, UK and
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Wilson RD, Gagnon A, Audibert F, Campagnolo C, Carroll J, Wilson RD, Audibert F, Brock JA, Campagnolo C, Carroll J, Chong K, Gagnon A, Johnson JA, MacDonald W, Okun N, Pastuck M, Vallee-Pouliot K. Prenatal Diagnosis Procedures and Techniques to Obtain a Diagnostic Fetal Specimen or Tissue: Maternal and Fetal Risks and Benefits. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2015; 37:656-668. [DOI: 10.1016/s1701-2163(15)30205-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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16
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Şükür YE, Göç G, Köse O, Açmaz G, Özmen B, Atabekoğlu CS, Koç A, Söylemez F. The effects of subchorionic hematoma on pregnancy outcome in patients with threatened abortion. J Turk Ger Gynecol Assoc 2014; 15:239-42. [PMID: 25584033 DOI: 10.5152/jtgga.2014.14170] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 10/09/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To assess the effects of ultrasonographically detected subchorionic hematomas on pregnancy outcomes in patients with vaginal bleeding within the first half of pregnancy. MATERIAL AND METHODS Patients diagnosed with threatened abortion due to painless vaginal bleeding and who were followed up in an in-patient service during the first vaginal bleeding between January 2009 and December 2010 were included in this retrospective cohort study. Patients were divided into two groups according to the presence of subchorionic hematoma. Miscarriage rates and pregnancy outcomes of ongoing pregnancies were compared between the groups. RESULTS There were no statistically significant differences between the groups regarding demographic parameters, including age, parity, previous miscarriage history, and gestational age at first vaginal bleeding. While 13 of 44 pregnancies (29.5%) with subchorionic hematoma resulted in miscarriage, 25 of 198 pregnancies (12.6%) without subchorionic hematoma resulted in miscarriage (p=.010). The gestational age at miscarriage and the duration between first vaginal bleeding and miscarriage were similar between the groups. The outcome measures of ongoing pregnancies, such as gestational week at delivery, birth weight, and delivery route, were also similar between the groups. CONCLUSION Ultrasonographically detected subchorionic hematoma increases the risk of miscarriage in patients with vaginal bleeding and threatened abortion during the first 20 weeks of gestation. However, it does not affect the pregnancy outcome measures of ongoing pregnancies.
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Affiliation(s)
- Yavuz Emre Şükür
- Department of Obstetrics and Gynaecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Göksu Göç
- Department of Obstetrics and Gynaecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Osman Köse
- Department of Obstetrics and Gynaecology, Yenimahalle State Hospital, Ankara, Turkey
| | - Gökhan Açmaz
- Department of Obstetrics and Gynaecology, Kayseri Education and Research Hospital, Kayseri, Turkey
| | - Batuhan Özmen
- Department of Obstetrics and Gynaecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Cem Somer Atabekoğlu
- Department of Obstetrics and Gynaecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Acar Koç
- Department of Obstetrics and Gynaecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Feride Söylemez
- Department of Obstetrics and Gynaecology, Ankara University Faculty of Medicine, Ankara, Turkey
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Xiang L, Wei Z, Cao Y. Symptoms of an intrauterine hematoma associated with pregnancy complications: a systematic review. PLoS One 2014; 9:e111676. [PMID: 25369062 PMCID: PMC4219764 DOI: 10.1371/journal.pone.0111676] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 09/27/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To evaluate the predictive value of the symptoms of an intrauterine hematoma (IUH) for adverse pregnancy outcomes. METHODS A literature review was performed with the search terms, including intrauterine/subchorionic/retroplacental/subplacental hematoma/hemorrhage/bleeding/collection/fluid, covering the period from January, 1981 to January, 2014. We just focused on the pregnancy outcomes associated with different symptoms of an IUH. RESULTS It is generally agreed that a retroplacental, posterior or subchorionic in the fundus of uterus, and/or persistent IUH is associated with adverse outcomes in the ongoing pregnancy. However, the prognosis value of both volume and gestational age at diagnosis of IUH still remains controversial. Some researchers argue that a large IUH is associated with an increased risk of adverse events during pregnancy while others refuted. It is believed by some that the earlier an IUH was detected, the higher the risk for adverse outcomes would be, while no or weak association were reported by other studies. The prognostic value of the simultaneous presence of vaginal bleeding on pregnancy outcome is also controversial. CONCLUSIONS Both the position relative to the placenta or uterus and duration of IUH have strong predictive value on the prognosis in the ongoing pregnancy. However, the prognostic values of the IUH volume, gestational age at diagnosis and the simultaneous presence of vaginal bleeding remain controversial up to now. Moreover, most of previous reports are small, uncontrolled studies with incomplete information. Prospective, large sample, cohorts studies which take all detailed symptoms of an IUH into consideration are needed when we evaluate its clinical significance in the prognosis of pregnancy.
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Affiliation(s)
- Lan Xiang
- Reproductive Medicine Center, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zhaolian Wei
- Reproductive Medicine Center, the First Affiliated Hospital of Anhui Medical University, Hefei, China
- * E-mail:
| | - Yunxia Cao
- Reproductive Medicine Center, the First Affiliated Hospital of Anhui Medical University, Hefei, China
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Xiang L, Wei Z, Wu J, Zhou P, Xiang H, Cao Y. Clinical significance of first-trimester intrauterine haematomas detected in pregnancies achieved by IVF-embryo transfer. Reprod Biomed Online 2014; 29:445-51. [DOI: 10.1016/j.rbmo.2014.06.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 06/20/2014] [Accepted: 06/23/2014] [Indexed: 11/16/2022]
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Wariki WMV, Goto Y, Ota E, Mori R. Cyclo-oxygenase (COX) inhibitors for threatened miscarriage. Hippokratia 2014. [DOI: 10.1002/14651858.cd011310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Windy MV Wariki
- Manado State University; Department of Public Health; Unima Campus Tondano North Sulawesi Indonesia 95618
| | - Yoshihito Goto
- Kyoto University School of Public Health; Department of Health Informatics; Yoshida Konoecho, Sakyo-ku Kyoto Japan 606-8501
| | - Erika Ota
- National Center for Child Health and Development; Department of Health Policy; 2-10-1 Okura, Setagaya-ku Tokyo Japan 157-8535
| | - Rintaro Mori
- National Center for Child Health and Development; Department of Health Policy; 2-10-1 Okura, Setagaya-ku Tokyo Japan 157-8535
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20
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Perinatal outcomes in singleton and twin pregnancies following first-trimester bleeding. J Perinatol 2014; 34:673-6. [PMID: 24786383 DOI: 10.1038/jp.2014.74] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Revised: 03/17/2014] [Accepted: 03/24/2014] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To investigate associations between first-trimester bleeding and perinatal outcomes. STUDY DESIGN Registry-based survey of the period 2002 through 2010. Pregnancies with versus without first-trimester bleeding were compared using Student's t- and χ(2)-test. Multivariable logistic regression was used to control for potential confounders. RESULT 9924 singleton and 275 twin pregnancies with first-trimester bleeding, and 160 099 singleton and 2710 twin pregnancies without bleeding were included. Bleeding increased the risk of preterm birth in singletons (odds ratio 1.48; 95% confidence interval 1.38-1.60). Risks were also increased for preterm premature rupture of membranes, abruption, previa, stillbirth and congenital anomalies, with a reduced risk of preeclampsia. The differences remained significant after adjustment for confounders. In twin pregnancies, bleeding was not significantly associated with prematurity (odds ratio 1.04; 95% confidence interval 0.81-1.34), nor with other outcomes. CONCLUSION In singletons, but not in twins, the risk of perinatal complications is significantly increased after first-trimester bleeding.
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Ozdemirci S, Karahanoglu E, Esinler D, Gelisen O, Kayıkcıoglu F. Influence of threatened miscarriage on pregnancy and early postpartum period: a case-control report. J Matern Fetal Neonatal Med 2014; 28:1186-9. [PMID: 25053196 DOI: 10.3109/14767058.2014.947577] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate the influence of threatened miscarriage on obstetric complications during pregnancy and early postpartum period. METHODS In this case-control study, hospital records of 12,050 first-trimester patients between January 2011 and December 2012 at the Research and Educational Hospital in Ankara, Turkey, were used. Of the 12,050 patients, 481 threatened miscarriage patients were evaluated. The control group was formed by age- and body mass index-matched cases without first trimester bleeding. Abortion, intrauterine foetal demise, preterm birth, preeclampsia, antenatal haematoma, uterine atony placental abruption and low birth-weights were compared between the study and the control group. RESULTS When compared with the control group, the risk of having a preterm birth (p = 0.014; OR: 1.95; 95% CI: 1.15-3.24), low-birth-weight infant (p = 0.001; OR: 2.33; 95% CI: 1.45-3.83) and abortion (p = 0.00; OR: 2.55; 95% CI: 1.62-3.91) increased in cases of threatened miscarriage. However, the risk of uterine atony was decreased (p = 0.006; OR: 0.09; 95% CI: 0.12-0.7) in the threatened miscarriage group when compared with the control group. Threatened miscarriage did not increase the risk of placenta praevia, placental abruption or intrauterine foetal demise. CONCLUSION Increased complications after threatened miscarriage is probably due to the persistence of a triggering mechanism. As preterm birth and abortion rate increased, whilst uterine atony rate decreased, one of the mechanisms causing threatened miscarriage might be increased uterine contractility.
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Affiliation(s)
- Safak Ozdemirci
- a Etlik Zubeyde Hanim Women's Health Education and Research Hospital , Ankara , Turkey
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Agrawal S, Khoiwal S, Jayant K, Agarwal R. Predicting adverse maternal and perinatal outcome after threatened miscarriage. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ojog.2014.41001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Elkholi DGEY, Nagy HM. Maternal serum concentrations of angiogenic and antiangiogenic factors in threatened miscarriage at 7–12weeks’ gestation and the risk of adverse pregnancy outcomes. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2013. [DOI: 10.1016/j.mefs.2013.01.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Costs and Clinical Outcomes of Noninvasive Fetal RhD Typing for Targeted Prophylaxis. Obstet Gynecol 2013; 122:579-85. [DOI: 10.1097/aog.0b013e31829f8814] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Evrenos AN, Cakir Gungor AN, Gulerman C, Cosar E. Obstetric outcomes of patients with abortus imminens in the first trimester. Arch Gynecol Obstet 2013; 289:499-504. [PMID: 23912531 DOI: 10.1007/s00404-013-2979-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 07/24/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE We aimed to find out the effect of abortus imminens (AI) on obstetric outcomes of pregnancies which continued beyond the 24th week of gestation. METHODS In this prospective study, 309 patients with AI were divided into high-risk group (with a risk factor for spontaneous abortus) (n = 92) and low-risk group (without a risk factor) (n = 217). The control group (n = 308) was chosen randomly. RESULTS In AI group, preterm delivery, preterm premature rupture of membranes (PPROM), cesarean section (C/S) delivery, postpartum uterine atony and need of a neonatal intensive care unit (NICU) rates were significantly higher than control group. Gestational diabetes mellitus, PPROM, still birth, low APGAR scores were seen more frequently in the high-risk patients than in the control group. Furthermore in the high-risk group, preterm delivery, malpresentation, C/S delivery and need of NICU were increased much more than in the low-risk group. Gestational hypertension/preeclampsia, oligo/polyhydramniosis, intrauterine growth retardation, placenta previa, abruption of placenta, chorioamnionitis, congenital abnormalities, delivery induction, cephalopelvic disproportion, fetal distress and manual removal of placenta were not different among the groups. CONCLUSIONS Patients with AI history, especially with high-risk factors can have adverse obstetric and neonatal results. So their antenatal follow-up has to be done cautiously for the early signs and symptoms of these complications.
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Affiliation(s)
- Ayşe Nur Evrenos
- Dr. Zekai Tahir Burak Women Health and Research Hospital, Ankara, Turkey
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Hosseini MS, Yaghoubipour S. Late pregnancy outcomes in women with vaginal bleeding in their first trimester. J Obstet Gynaecol India 2013; 63:311-5. [PMID: 24431665 DOI: 10.1007/s13224-013-0389-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Accepted: 01/27/2013] [Indexed: 11/29/2022] Open
Abstract
PURPOSE First trimester vaginal bleeding (FTVB) does not usually terminate the pregnancy. However, its outcome is a matter of debate. This study sought to assess the outcomes of pregnancies, complicated by FTVB. METHODS In this cohort study, 236 gravida 1 and 2 FTVB patients with delivery after 28 weeks of gestational age, admitted to Imam Hossein Hospital during 2009-2010, were evaluated. The control group consisted of 944 gravida 1 and 2 women without any history of vaginal bleeding. Late pregnancy outcomes such as gestational hypertension, preeclampsia, placental abruption, preterm delivery, and premature rupture of membranes in the mothers and low birth weight (LBW), intrauterine growth restriction(IUGR), Apgar score at 5 min <7, and NICU admission in the infants were evaluated. Logistic regression was used for estimation of odds ratios (OR) and 95 % confidence interval. RESULTS Compared to controls, the FTVB cases had more premature rupture of membranes (OR = 10), gestational hypertension (OR = 5.3), and placental abruption (OR = 4.7), while their infants had higher odds of LBW, IUGR, Apgar score at 5 min <7, and admission to NICU too. The incidence of premature rupture of membranes was 3.6 % in the controls and 27.1 % in the cases (RR = 10, P < 0.001). The incidence of gestational hypertension and LBW was 1.5 and 7.2 % (P < 0.001) in the controls and 6.6 and 12.3 % (P < 0.001) in the cases. The other outcomes were similar in both groups. CONCLUSION FTVB may play a role in the development of late pregnancy outcomes in mothers and infants. Thus, it is recommended to evaluate some interventions on FTVB cases to prevent complications.
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Affiliation(s)
- Maryam Sadat Hosseini
- Department of Gynecology, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Dekker GA, Lee SY, North RA, McCowan LM, Simpson NAB, Roberts CT. Risk factors for preterm birth in an international prospective cohort of nulliparous women. PLoS One 2012; 7:e39154. [PMID: 22815699 PMCID: PMC3398037 DOI: 10.1371/journal.pone.0039154] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Accepted: 05/16/2012] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To identify risk factors for spontaneous preterm birth (birth <37 weeks gestation) with intact membranes (SPTB-IM) and SPTB after prelabour rupture of the membranes (SPTB-PPROM) for nulliparous pregnant women. DESIGN Prospective international multicentre cohort. PARTICIPANTS 3234 healthy nulliparous women with a singleton pregnancy, follow up was complete in 3184 of participants (98.5%). RESULTS Of the 3184 women, 156 (4.9%) had their pregnancy complicated by SPTB; 96 (3.0%) and 60 (1.9%) in the SPTB-IM and SPTB-PPROM categories, respectively. Independent risk factors for SPTB-IM were shorter cervical length, abnormal uterine Doppler flow, use of marijuana pre-pregnancy, lack of overall feeling of well being, being of Caucasian ethnicity, having a mother with diabetes and/or a history of preeclampsia, and a family history of low birth weight babies. Independent risk factors for SPTB-PPROM were shorter cervical length, short stature, participant's not being the first born in the family, longer time to conceive, not waking up at night, hormonal fertility treatment (excluding clomiphene), mild hypertension, family history of recurrent gestational diabetes, and maternal family history of any miscarriage (risk reduction). Low BMI (<20) nearly doubled the risk for SPTB-PPROM (odds ratio 2.64; 95% CI 1.07-6.51). The area under the receiver operating characteristics curve (AUC), after internal validation, was 0.69 for SPTB-IM and 0.79 for SPTB-PPROM. CONCLUSION The ability to predict PTB in healthy nulliparous women using clinical characteristics is modest. The dissimilarity of risk factors for SPTB-IM compared with SPTB-PPROM indicates different pathophysiological pathways underlie these distinct phenotypes. TRIAL REGISTRATION ACTR.org.au ACTRN12607000551493.
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Calleja-Agius J, Muttukrishna S, Pizzey AR, Jauniaux E. Pro- and antiinflammatory cytokines in threatened miscarriages. Am J Obstet Gynecol 2011; 205:83.e8-16. [PMID: 21514552 DOI: 10.1016/j.ajog.2011.02.051] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Revised: 01/25/2011] [Accepted: 02/14/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate circulating and intracellular levels of Th1 and Th2 cytokines in women with threatened miscarriage (TM) and subsequent outcome. STUDY DESIGN Plasma levels of tumor necrosis factor (TNF)-receptors 1 and 2, TNFα, interferon gamma (IFNγ), and interleukins (IL) -6 and -10 were measured by flow cytometric bead assays in 80 women with TM: 53 women with normal outcome and 27 women who miscarried. Fluorescent antibody labeling was also performed on whole blood in a subgroup of 27 women of TM: 16 women with normal outcome and 11 women who miscarried. RESULTS Monocyte expression of TNFα and circulating levels of TNFα, IFNγ, IL-10, IL-6, and TNF-R1 were significantly lower, whereas circulating levels of TNFα/IL-10, IFNγ/IL-10, and TNFα/IL-6 ratios were significantly higher, in women with TM who subsequently miscarried, compared with the women with normal outcome. CONCLUSION An increased Th1 type of immune response, which was similar to that observed in preterm delivery, was found in TM cases that were complicated by a subsequent miscarriage.
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Hackney DN, Glantz JC. Vaginal bleeding in early pregnancy and preterm birth: systemic review and analysis of heterogeneity. J Matern Fetal Neonatal Med 2011; 24:778-86. [PMID: 21142755 PMCID: PMC4547549 DOI: 10.3109/14767058.2010.530707] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To systemically review published studies of vaginal bleeding and the risk of preterm birth (PTB) and explore sources of heterogeneity between them. METHODS The literature was searched for peer-reviewed articles from 1980 to 2009 in which the primary analysis was the risk of PTB among low-risk subjects with and without bleeding. Heterogeneity was assessed through I(2) statistics, and sources of heterogeneity were explored through subgroup analyses and meta-regression. RESULTS 218 studies were initially identified, 64 reviewed and 23 included. The pooled Odds Ratio for PTB was 1.74, though significant heterogeneity was present (I(2) = 49.7%). Meta-regression demonstrated a significant association between a study's incidence of bleeding and quality assessment and subsequent odds ratio, such that studies with a lower quality assessment or lower incidence of bleeding demonstrated an increased odds of PTB. CONCLUSIONS Bleeding in early pregnancy is associated with an increased risk of PTB; however, excessive heterogeneity exists among published studies. The heterogeneity arises in part from differences in the reported incidence of bleeding within study populations. Presumably studies that identify bleeding in a larger percentage of subjects consequently dilute the magnitude of the risk.
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Affiliation(s)
- David N Hackney
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine, Rochester, New York, USA.
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Calleja-Agius J, Schembri-Wismayer P, Calleja N, Brincat M, Spiteri D. Obstetric outcome and cytokine levels in threatened miscarriage. Gynecol Endocrinol 2011; 27:121-7. [PMID: 20500112 DOI: 10.3109/09513590.2010.487614] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To evaluate the proportion of women with threatened miscarriage (TM) who proceed to miscarriage in a population of single ethnicity and to investigate prospectively their risk of adverse pregnancy outcome in relationship with the cytokines levels in their circulation. METHODS We conducted a prospective observational study over a period of 1 year of 94 Maltese women presenting with TM at the same hospital and compared their clinical data with those of 564 age-matched controls from the National Obstetric Information System (NOIS) of Malta. Main outcome measures included gestational age and weight at delivery and incidence of adverse pregnancy outcomes. A pilot study was carried out, where in subgroups of 10 women with TM (n=10), non-pregnant women (n=12), normal pregnant controls (n=9) and women presenting with missed-miscarriage (n=11), the plasma levels of β-human chorionic gonadotrophin (β-hCG), tumour necrosis factor α (TNFα), interferon γ (IFNγ), interleukin-6 (IL-6), interleukin-10 (IL-10) and TNF-receptors 1 (R1) and 2 (R2) were measured. RESULTS Of the women presenting with TM, 25 (26.6%) proceeded to complete miscarriage. The TM group had also a significantly higher incidence of antepartum haemorrhage (p<0.005), pre-eclampsia (p<0.05), foetal growth restriction (p<0.05), premature labour (p<0.001) and retained placenta (p<0.005). In the pilot biochemical analysis, significantly (p<0.05) higher levels of TNFα and lower levels of TNFR2 were found in the TM subgroup compared to non-pregnant controls. The ratio TNFα/IL-10 was significantly (p<0.05) higher and the β-hCG levels was significantly lower (p<0.01) in missed-miscarriage and non-pregnant subgroups than in TM and normal pregnant controls. The IFNγ/1L-10 and IFNγ/1L-6 ratio were significantly (<0.001) different between the four subgroups with the lowest level found in TM. No similar gradient was found for the TNFα/1L-6 ratio. CONCLUSION Women presenting with TM are at significantly increased risk of adverse pregnancy outcome and the pathophysiology of these conditions involves a change in the Th1/Th2 balance. Changes in levels of cytokines could help to predict and thus prevent the development of some of these complications.
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Affiliation(s)
- Jean Calleja-Agius
- EGA, Institute for Women's Health, Department of Obstetrics and Gynaecology, University College London (UCL), London, United Kingdom.
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Calleja-Agius J, Calleja N, Brincat M, Spiteri D. Obstetric outcome in cases of threatened spontaneous abortion. Int J Gynaecol Obstet 2010; 110:75-6. [PMID: 20494355 DOI: 10.1016/j.ijgo.2010.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 02/18/2010] [Accepted: 03/15/2010] [Indexed: 11/28/2022]
Affiliation(s)
- Jean Calleja-Agius
- Department of Obstetrics and Gynaecology, University of Malta, Tal-Qroqq, Birkirkara, Malta.
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Abstract
OBJECTIVE To evaluate the association of first-trimester bleeding without miscarriage and complications later in the first pregnancy as well as in the next pregnancy. METHODS In a retrospective, registry-based cohort study, we identified women delivering in Denmark from 1978 to 2007 with a first singleton pregnancy (n=782,287) and first and second singleton pregnancies (n=536,419). First-trimester bleeding is defined as vaginal bleeding before 12 full weeks of gestation. We employed multivariate logistic regression with adjustment for maternal age and calendar year. RESULTS First-trimester bleeding increased the risk of delivery in weeks 32-36 from 3.6% to 6.1% (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.57-1.77) and in weeks 28-31 from 0.3% to 0.9% (OR 2.98; 95% CI 2.50-3.54) and increased the risk of placental abruption from 1.0% to 1.4% (OR 1.48; 95% CI 1.30-1.68). First-trimester bleeding in the first pregnancy increased the risk of recurrence in the second pregnancy from 2.2% to 8.2% (OR 4.05; 95% CI 3.78-4.34), preterm delivery from 2.7% to 4.8% (OR 1.83; 95% CI 1.67-2.00), and placental abruption from 0.9% to 1.0% (OR 1.29; 95% CI 1.07-1.56) in the second pregnancy. CONCLUSION Women with first-trimester bleeding in the first pregnancy have an increased risk of complications later in the first pregnancy and of recurrence of first-trimester bleeding and other complications in the second pregnancy.
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Neural networks prediction of preterm delivery with first trimester bleeding. Arch Gynecol Obstet 2010; 283:971-9. [PMID: 20449599 DOI: 10.1007/s00404-010-1469-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2009] [Accepted: 04/08/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This paper illustrates a retrospective study of the outcome of those pregnancies that continued from an initial episode of bleeding in first trimester. METHODS Neural networks is used for the prediction of preterm delivery, using various inputs such as the age of women, gestational age when the bleeding occurred, duration of the bleeding days, amount of bleeding, number of episodes, presence or absence of hematoma and placentation position. RESULTS The success rate of prediction obtained using the feed forward backpropogation network is 70%. Hence, this model can be used to identify women at the risk of premature delivery for planning antenatal care and clinical interventions in pregnancy.
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A comparison between the pregnancy outcome in women both with or without threatened abortion. Early Hum Dev 2010; 86:193-6. [PMID: 20231080 DOI: 10.1016/j.earlhumdev.2010.02.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2010] [Revised: 02/16/2010] [Accepted: 02/17/2010] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the pregnancy outcome in pregnancies with threatened abortion (miscarriage). MATERIAL AND METHOD A prospective cohort study was performed on 1000 pregnant women. 500 women (case group), had a history of vaginal bleeding during the first half of pregnancy and the other 500 women (control group), did not have this history. Both groups of women were monitored from 20 weeks of pregnancy up to delivery. RESULTS The women of the 2 groups did not have any significant differences according to age, parity or body mass index (BMI). Spontaneous preterm delivery [126 cases (25.2%) vs. 47 cases (9.4%), P=0.001, adj RR=1.4, CI 95%=1.2-1.5], PROM [51 cases (10.2%) vs. 24 cases (4.8%), P=0.02, adj RR=2.1, CI95%=1.2-2.3], placental abruption [20 cases (4%) vs. 7 cases (1.4%) P=0.01, adj RR=1.1, CI 95%=1.01-1.2], were more in the case group. There were no differences between the 2 groups with regard to Preeclampsia, small for gestational age (SGA), and cesarean deliveries. Neonatal weight (in term pregnancies) in the case group was lower than in the control group (3046.4+/-560.8 g vs. 3317.6+/-432 g, P=0.001). There was a significant relationship between the number of bleeding episodes, spontaneous preterm delivery and placental abruption and there was also a significant relationship between the amount of bleeding and placental abruption. CONCLUSION Threatened abortion increases the rate of spontaneous preterm delivery, PROM and placental abruption, and decreases the neonatal weight. Therefore threatened abortion indicates a high risk pregnancy and, as such, demands more serious prenatal care.
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Qureshi N. Treatment options for threatened miscarriage. Maturitas 2009; 65 Suppl 1:S35-41. [DOI: 10.1016/j.maturitas.2009.10.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2009] [Revised: 10/28/2009] [Accepted: 10/28/2009] [Indexed: 11/26/2022]
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Saraswat L, Bhattacharya S, Maheshwari A, Bhattacharya S. Maternal and perinatal outcome in women with threatened miscarriage in the first trimester: a systematic review. BJOG 2009; 117:245-57. [DOI: 10.1111/j.1471-0528.2009.02427.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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van Oppenraaij R, Jauniaux E, Christiansen O, Horcajadas J, Farquharson R, Exalto N. Predicting adverse obstetric outcome after early pregnancy events and complications: a review. Hum Reprod Update 2009; 15:409-21. [DOI: 10.1093/humupd/dmp009] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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