Comparison of colour Doppler features and pathological findings in complicated early pregnancy

Resistance index (RI) and pulsatility index (PI) in the uterine and spiral arteries, uterine artery peak systolic velocity and intervillous blood flow were recorded by transvaginal colour Doppler imaging in 30 missed abortions and 30 normal pregnancies matched for menstrual age. Pathological examination was performed in both groups within 24 h of Doppler investigation. The mean uterine PI was significantly (P < 0.01) higher in missed abortions compared to normal controls, whereas the mean uterine RI and peak systolic velocity and spiral RI and PI did not differ. A continuous intervillous flow was found in 16 out of 23 (69.6%) of the complicated pregnancies before 12 weeks of gestation whereas it was not found in controls. In the missed abortion cases, the trophoblastic shell was fragmented or absent in 53% and trophoblastic infiltration and physiological changes in the spiral arteries were reduced or absent in 43 and 63%, respectively. These findings were not related to normal or abnormal Doppler indices. Extended dislocation of the trophoblastic shell and a massive infiltration of the intervillous space and placental bed by maternal blood was also found in cases presenting with a continuous intervillous blood flow before 12 weeks of gestation. These findings suggest that abnormal flow velocity waveforms in early pregnancies complicated by embryonic death are related to deficient placentation and dislocation of the trophoblastic shell that follows embryonic demise. The premature entry of maternal blood into the intervillous space disrupts the materno-embryonic interface and is probably the final mechanism causing abortion.

Misoprostol for medical evacuation of early pregnancy failure

OBJECTIVE

To determine whether misoprostol (a prostaglandin E1 analogue) 400 micrograms orally (group 1) or 800 micrograms vaginally (group 2) will cause complete uterine evacuation in women with early pregnancy failure.

METHODS

Twenty subjects were recruited for a prospective, non-blinded, randomized clinical trial. Early pregnancy failure was diagnosed by transvaginal ultrasound examination; only women with a closed cervical os and minimal vaginal bleeding were enrolled. Subjects returned 24 hours after misoprostol administration for a transvaginal ultrasound examination. If the gestational sac was still present, the misoprostol dose was repeated and the subject returned again 24 hours later. Subjects who failed to expel the pregnancy were offered a suction curettage.

RESULTS

Twelve and eight women were randomized to groups 1 and 2, respectively. Complete uterine evacuation occurred in three of 12 [25%, 95% confidence interval (CI) 1%, 50%] and seven of eight (88%, 95% CI 65%, 100%, P = .010) subjects in groups 1 and 2, respectively. Vomiting occurred in 30% and 13%, respectively, and diarrhea in 50% and 38%, respectively.

CONCLUSION

Vaginal misoprostol 800 micrograms is more effective than oral misoprostol 400 micrograms for uterine evacuation of early pregnancy failure and may be an effective alternative to dilation and curettage.

The diagnostic implications of routine ultrasound examination in histologically confirmed early molar pregnancies

OBJECTIVE

Early ultrasound examination is being used increasingly in the diagnosis of molar pregnancy. The aim of this study was to examine the diagnostic implications of routine ultrasound examination for histologically confirmed molar pregnancies.

METHODS

This was a retrospective review of sonographic and histological findings in a series of consecutive cases referred to the National Trophoblastic Disease Surveillance Centre with suspected molar pregnancies. In 194 cases referred to the center over a 6-month period in whom results of a preceding ultrasound examination were documented, review of ultrasound findings and final histological diagnosis was carried out.

RESULTS

There were 155 cases with a reviewed histological diagnosis of complete or partial hydatidiform mole. In 131 (67%) cases, the sonographic diagnosis was that of a missed miscarriage/anembryonic pregnancy with no documented suspicion of molar pregnancy, referral being on the basis of histological examination of products of conception. In 63 cases, ultrasound examination suggested molar pregnancy; in 53 (84%) of these, the diagnosis of molar pregnancy was correct. Overall, 37 of 64 (58%) complete moles had sonographic evidence of molar pregnancy compared to 16 of 91 (17%) partial moles. Of 155 histologically confirmed complete or partial hydatidiform moles, only 53 (34%) were suspected as molar sonographically.

CONCLUSION

The majority of cases of molar pregnancy now present as missed miscarriage/anembryonic pregnancy sonographically, highlighting the importance of histological examination to diagnose gestational trophoblastic disease.

Expectant management of missed miscarriage

The option of expectant management was offered 221 women with ultrasound diagnosis of missed miscarriage. Eighty-five women (38%) accepted; the remaining 136 women chose surgical evacuation of retained products of conception. In the expectant management group 21 women (24.7%) had a complete miscarriage, 14 (16.5%) had incomplete miscarriage necessitating surgery, and 50 (58.8%) requested surgery within 48 days from the original diagnosis. These results suggest that the success of expectant management of missed miscarriage is too low to justify its use in routine clinical practice.

The prevalence of non-viable pregnancy at 10-13 weeks of gestation

In an ultrasound screening study at 10-13 weeks of gestation involving 17,870 women, the prevalence of early pregnancy failure was 2.8% (501 cases), including 313 (62.5%) missed abortions and 188 (37.5%) anembryonic pregnancies. Lower gestation and higher maternal age were associated with a higher prevalence (chi 2 = 143.5; p < 0.001 and chi 2 = 53.3; p < 0.0001, respectively). The prevalence was higher in women with a history of vaginal bleeding (chi 2 = 141.5; p < 0.0001), but there was no significant association with previous pregnancy losses (chi 2 = 2.8), parity (chi 2 = 0.6) or cigarette smoking (chi 2 = 0.0). Recent evidence suggests that the most effective method of screening for chromosomal abnormalities is measurement of fetal nuchal translucency thickness at 10-13 weeks, and therefore ultrasound examination at this gestation is likely to become universally available. As shown in this study, an additional advantage of such a scan is the diagnosis of early pregnancy failure, which will be found in about 3% of patients examined. Elective evacuation of retained products of conception is likely to be more cost effective and potentially safer than emergency surgery in a patient presenting during miscarriage.

Iatrogenic secondary infertility caused by residual intrauterine fetal bone after midtrimester abortion

Eleven women with secondary infertility had ultrasonographic findings of intrauterine calcification. Infertility developed in all women after operative termination of midtrimester pregnancy. Dilation and curettage or hysteroscopic removal confirmed residual fetal bony fragments. The removal of these bony fragments was associated with therapeutic success for infertility.

Medical management of missed abortion: a randomized clinical trial

OBJECTIVE

To estimate the efficacy of vaginal misoprostol for medical management of missed abortion.

METHODS

Fifty women with missed abortion were randomized to treatment with up to two 800 microg [DOSAGE ERROR CORRECTED] doses of misoprostol vaginally or a placebo. Participants were reviewed daily for 2 days, then again at 1 week. A blood sample for hemoglobin and serum beta-human chorionic gonadotropin (beta hCG) was obtained on day 1 and the hemoglobin level checked again on day 7. Complete abortion was defined as expulsion of the products of conception without dilation and curettage (D&C) and a negative follow-up urine beta hCG test after 4 weeks, or as no products of conception obtained at D&C in cases of suspected incomplete abortion.

RESULTS

The rate of complete abortion was 80% (20 of 25) in the misoprostol group and 16% (four of 25) in the placebo group, relative risk 0.20 (0.08, 0.50), P <.001. The rate of D&C was 28% (seven of 25) in the misoprostol group and 84% (21 of 25) in the placebo group, relative risk 0.33 (0.17, 0.64), P <.001. One participant in the misoprostol group had an emergency D&C for heavy bleeding. No participants required blood transfusion. The mean reduction in hemoglobin from day 1 to day 7 was 3.2 g/L in the misoprostol group versus 4.3 g/L in the placebo group, P = .72. Patient satisfaction with misoprostol treatment was high with 19 of 21 participants reporting they would try medical management again if they experienced another missed abortion.

CONCLUSION

Medical management of missed abortion is effective, reduces the need for D&C, and is associated with high levels of patient satisfaction.

How should success be defined when attempting medical resolution of first-trimester missed abortion?

OBJECTIVES

There is currently no consensus on how success should be defined after medical management of first-trimester missed abortion. The aim of this study was to determine the transvaginal ultrasound criterion associated with highest success rate and, at the same time, lowest long-term complications.

DESIGN

Prospective observational study of consecutively enrolled patients.

SETTING

A tertiary care university hospital in northern Portugal.

PARTICIPANTS

Forty-four women submitted to medical management of first-trimester missed abortion using a regimen of vaginal misoprostol, with histologically confirmed conception products passed vaginally. A transvaginal ultrasound scan was performed by an experienced sonographer in the morning after treatment, to characterise uterine content. Patients were provided with a chart for daily registration of axillary temperature, vaginal bleeding and lower abdominal pain. Transvaginal ultrasound was repeated 2-3 weeks later, and again after the following menses.

MAIN OUTCOME MEASURES

Success rates of medical management when post-treatment transvaginal ultrasound criteria for subsequent expectant management were: absence of intra-uterine sac, largest anteroposterior diameter of hyperechogenic content, and maximum area of hyperechogenic intra-uterine content in a sagittal view. Self-reported duration of vaginal bleeding and abdominal pain after medical treatment.

RESULTS

Success rate was 86% (38/44) when absence of gestational sac on the 12 h transvaginal ultrasound was used as the main criterion for subsequent expectant management and there was no need for further intervention. The success rate using the ultrasound criterion anteroposterior diameter < or = 15 mm was 51% (22/43), and with maximum sagittal plane area under 7.5 cm(2), 72% (31/43). Mean duration of vaginal haemorrhage was 9 days (minimum 2 days, maximum 14 days) and of lower abdominal pain 6 days (minimum 0 days, maximum 14 days). No patient recorded an axillary temperature exceeding 37 degrees C. No apparent relationship between the size of ultrasound-estimated intra-uterine content and duration of symptoms was observed.

CONCLUSIONS

Absence of gestational sac on transvaginal ultrasound should be the criterion used to document success after medical management of first-trimester missed abortion, as it is associated with the highest short and long-term success rates, as well as mild and self-limited symptoms in the days following treatment.

Vaginal misoprostol in the management of first-trimester missed abortions

OBJECTIVE

To evaluate the efficacy of a regimen of vaginal misoprostol in causing the complete expulsion of first-trimester missed abortions, or alternatively dilating the cervix for surgical evacuation.

METHOD

Seventy-four women with a transvaginal ultrasound diagnosis of a first-trimester missed abortion and no more than slight vaginal bleeding were consecutively enrolled. Misoprostol (600 microg) was administered vaginally and repeated 4 h later if necessary. Surgical evacuation was performed when complete expulsion was not documented on the ultrasound 10-12 h after treatment.

RESULTS

Complete medical evacuation occurred in 42 women (56.8%), 11 (14.9%) of which required only one dose. Seventy women (94.6%) experienced abdominal pain, 73 (98.6%) vaginal bleeding, 10 (13.5%) nausea, 4 (5.4%) vomiting, 5 (6.8%) diarrhea, and 4 (5.4%) transient hyperthermia. There was one case of heavy vaginal bleeding requiring emergency surgical evacuation, and one re-admission for incomplete abortion at 30 days. All but 4 (5.4%) women had permeable cervices at the time of surgery.

CONCLUSION

The described regimen of vaginal misoprostol is safe and reasonably effective in inducing complete evacuation in missed abortions. When this does not occur, it almost always provides adequate cervical dilatation for surgery.

Parallel Doppler assessment of yolk sac and intervillous circulation in normal pregnancy and missed abortion

This study assessed yolk sac morphology and vascularity and intervillous blood flow in normal early pregnancy and missed abortion. Transvaginal colour and pulsed Doppler were used in a prospective analysis of 87 normal pregnancies and 48 missed abortions between 6 and 12 weeks gestation. The Kruskal-Wallis rank test was used to calculate the difference in yolk sac diameter and vascularity visualization rate between gestational weeks. Repeated measures analysis of variance was used for comparison of the intervillous circulation between groups. The growth of the yolk sac was considered statistically significant between gestational weeks 6 and 9, being most prominent between 9 and 10 weeks of gestation. Vascularity of the yolk sac, characterized by low velocity and absence of diastolic flow, was demonstrated in 67 per cent of normal pregnancies. Yolk sac blood flow was detected in 19 per cent of the patients with missed abortion. Doppler analysis of the intervillous circulation demonstrated decreased peak velocity of the continuous flow in patients with missed abortion for gestational weeks 11 and 12. It is concluded that progressive decrease of yolk sac vascularity coincides with visualization of more prominent colour-coded areas within the intervillous space. In patients with missed abortion, such changes do not occur.

Transvaginal color Doppler in the assessment of abnormal early pregnancy

The study groups comprised 61 pregnant women whose gestational age ranged from 7 to 12 weeks from the last menstrual period. All patients apparently had a normal developing pregnancy; there were no clinical symptoms of pathology e.g. bleeding in early pregnancy. Eighty-two patients with a clinically and ultrasonographically normal pregnancy whose gestational age ranged from 7 to 12 weeks, served as a control group. When the anatomical position of investigated area have been obtained clearly, pulsed wave Doppler sample volume was placed on the structures of interest: the both uterine arteries and intervillous space. There is no statistically significant difference between the Resistance Index (RI) in the left or right uterine artery (P greater than 0.01) and among investigated groups of patients (P greater than 0.01). The intervillous blood flow RI in the case of molar pregnancy was 0.38 with SD +/- 0.03; in blighted ovum 0.43 with SD +/- 0.03, and in missed abortion 0.43 with SD +/- 0.02. It should be stressed that in nine (31%) cases of blighted ova and in five (26%) cases of missed abortion, intervillous space flow could not be detected. In the control group, intervillous blood flow was always visualized and the mean RI was 0.45 with SD - 0.04. Statistical analysis showed significantly higher RI in control group in comparison with other groups of patients (P less than 0.01), and significantly lower RI in molar pregnancy in comparison with other groups of patients (P less than 0.01). There was no difference in RI between blighted ova and missed abortions (P greater than 0.01).

Intravaginal misoprostol 600 microg and 800 microg for the treatment of early pregnancy failure

OBJECTIVE

To compare the respective effectiveness and safety of 600 microg and 800 microg of intravaginal misoprostol for complete abortion in cases of early pregnancy failure (occurring in the first 12 weeks).

METHOD

A total of 114 women with a diagnosis of early pregnancy failure made by transvaginal ultrasonography at Rajavithi Hospital between November 25, 2002 and July 31, 2003, were assigned randomly to 2 groups of equal size. In one group the women received 600 microg of misoprostol and in the other 800 microg of misoprostol intravaginally.

RESULTS

The rate of complete abortion within 24 h was significantly higher in the group that received 800 microg of misoprostol (68.4%) than in the other group (45.6%) (P<0.05). There were no significant differences between the 2 groups regarding time interval between misoprostol insertion and complete abortion or side effects.

CONCLUSION

Intravaginal misoprostol 800 microg is significantly more effective than vaginal misoprostol 600 microg for the termination of an early pregnancy failure, with no significant differences in side effects.

Postmortem chorionic villus sampling: correlation of cytogenetic and ultrasound findings

We performed chorionic villus samplings (CVS) in 795 cases in the first trimester during a 13-month period. Of these 35 were found to have a blighted ovum or missed abortion prior to the procedure. Nineteen women consented to have CVS. Ultrasonographic and cytogenetic findings in these 19 pregnancies were correlated. Expected gestational age was determined by last menstrual period. Observed gestational age was determined by crown rump length (CRL) (12 pregnancies) or gestational sac (GS) (7 pregnancies without fetal pole). The differences in days between the estimated and observed gestational ages was determined for each pregnancy. In all 19 CVS samples cytogenetic diagnosis documented aneuploidy. Ten cases had chromosome abnormalities virtually always lethal in the embryonic period (group I). Nine pregnancies had defects with moderate potential for fetal viability (group II). Gestations with low viability potential (group I) had estimated minus observed gestational age discrepancies (23.4 +/- 8.3 days) significantly greater than gestations with moderate viability potential (group II) (8.9 +/- 4.3 days) (P less than .001). The absence of a fetal pole was more common in group I. CVS in pregnancies with missed abortion or blighted ovum is feasible and has a high likelihood of documenting aneuploidy. Furthermore, the more severe the anomaly the more likely there will be very early fetal demise or intrauterine growth retardation.

Subclavian vein thrombosis: a late complication of ovarian hyperstimulation syndrome

Two cases of subclavian vein thrombosis following ovarian stimulation for in-vitro fertilization and subsequent ovarian hyperstimulation syndrome (OHSS) are described. Both occurred several weeks after complete resolution of the OHSS. The site of the lesions and their timing suggest that there is a generalized disturbance of coagulation associated with OHSS, which persists beyond the duration of the clinical syndrome.

Cytogenetic testing of anembryonic pregnancies compared to embryonic missed abortions

PURPOSE

The objective of this study is to determine the rate of abnormalities detected by cytogenetic testing of first trimester miscarriages, in patients with and without an embryonic pole seen on ultrasound.

MATERIALS AND METHODS

A retrospective study of 272 D&Cs for missed abortions in an academic infertility practice from 1999 to 2006. Karyotype results were compared with transvaginal ultrasound findings. Chi-squared analysis was used with a P < 0.05 for significance.

RESULTS

There was a high rate of abnormal karyotypes in all miscarriages (65%). Rates of abnormal karyotypes were 58% and 68% in cases with anembryonic gestations and those with a fetal pole seen, respectively (P > 0.05).

CONCLUSION

The high rate of abnormalities detected in both groups suggests that useful results can be obtained from chromosomal testing of the POC regardless of ultrasound findings. Further studies on the prognostic value and cost effectiveness of chromosomal testing are needed.

Missed abortion complicated by Candida infection in a woman with rested IUD

Although Candida species are frequent saprophytes of the female genital tract, chorioamnionitis or intrauterine fetal infections are rarely caused by these fungi. The present report describes a 34-year-old woman G2, P2, presenting with vaginal bleeding in the 11.6 weeks of gestation. Clinical and sonographic examination revealed a missed abortion and rested IUD. Histopathologically, a fungal chorioamnionitis due to Candida spp. was found at the curetting material, confirmed by detection of C. albicans infection on mycological culture. Foreign intrauterine bodies, like IUD's and cerclage sutures predispose to fungal chorioamnitis or fetal infections. This conditions urge repetetive search for Candida spp. to establish early anti-fungal therapy which may be therapeutic for this hithero rare intrauterine infection.

Medical management of first trimester miscarriage (blighted ovum and missed abortion): is it effective?

This prospective study of 104 women investigated the dose-related efficacy of mifepristone combined with oral misoprostol in the management of first trimester miscarriage (missed abortion and blighted ovum). Forty-four women (group A) received 600 mg of oral mifepristone and 60 women (group B) received 200 mg of mifepristone, followed after 48 hours by oral misoprostol. Successful treatment was an empty uterus on scan and no bleeding after 10 days. This was achieved in 70.5% of group A and 66.7% of group B. Also studied were amount and time to cessation of bleeding, pain scores, analgesic requirements, adverse effects and infections. Of group A, 54.5% had heavy bleeding and bleeding stopped on average by 8 days. Median pain scores were 5.5 on a linear scale and 18% of women received intramuscular opiate analgesia. Adverse effects were nausea in 25% of women and diarrhoea in 16%. Of group B, 38.3% had heavy bleeding and bleeding stopped on average by 7 days. Median pain scores were 4.5 with 25% of women receiving intramuscular opiates. Nausea occurred in 7% of women and diarrhoea in 7%. We concluded that 200 mg of mifepristone and oral misoprostol is as effective and better tolerated than 600 mg mifepristone with oral misoprostol. Medical management of miscarriage is a valid option for those women seeking an alternative to traditional surgical management.

Medical termination of missed abortion

Missed abortions are a common occurrence and represent a heavy gynaecological emergency workload to both medical and nursing staff. The conventional method using vacuum aspiration of uterus is associated with morbidity and mortality. Medical termination of pregnancy is accepted as a safe and effective alternative method. However, medical evacuation of uterus in missed abortions had not been fully investigated. In this study we hope to examine the efficacy of medical methods for terminating missed abortions. Mifepristone and misoprostol prescribed to 100 women with an ultrasonically confirmed missed abortion was compared with 100 women who had surgical evacuation under general anaesthesia for their missed abortion. The disparity in complications between medical and surgical groups was not significantly different (Student's t-test, P=0.5). This study showed medical evacuation of missed abortion to be an effective, safe and cost-effective, alternative to surgical evacuation of the uterus and is particularly suited to women not wanting hospital admission or a surgical procedure under general anaesthesia. It represents an option of management that can be less intrusive and gives the woman some control but is both safe and effective.

Expectant management of spontaneous first-trimester miscarriage: prospective validation of the '2-week rule'

OBJECTIVES

To assess uptake and success of expectant management of first-trimester miscarriage for a finite 14-day period, in order to evaluate our '2-week rule' of management.

METHODS

This was a prospective observational study evaluating our proposed 2-week rule of expectant management, which is based on the finding that women managed expectantly are most likely to miscarry in the first 14 days and that to wait longer than 2 weeks without intervention does not confer a greater chance of successful resolution. Eligible women diagnosed with first-trimester miscarriage were offered a choice of expectant management or surgical evacuation under general anesthesia. Inclusion criteria for expectant management were: diagnosis of incomplete miscarriage (heterogeneous tissue, with or without a gestational sac, seen on ultrasound in the uterine cavity and distorting the endometrial midline echo), missed miscarriage (crown-rump length (CRL) >or= 6 mm with absent fetal heart activity) or empty sac (anembryonic pregnancy) based on transvaginal ultrasonography. Women with complete miscarriage, missed miscarriage at the nuchal translucency scan, molar pregnancy or miscarriage >or= 3 weeks in duration (missed miscarriage in which the CRL was >or= 3 weeks smaller than the gestational age based on last menstrual period), or with signs of infection or hemodynamic instability were excluded. Expectant management consisted of weekly ultrasonography for 2 weeks. If after 2 weeks resolution was not complete, surgery was advised.

RESULTS

1062 consecutive pregnant women underwent transvaginal ultrasound examination. Of these, 38.6% (410/1062) were diagnosed with miscarriage, of whom 241 (59%) were symptomatic at the time of presentation and 282 were eligible for the study. These were offered expectant management and 80% (227/282) took up this option. 11% (24/227) were lost to follow-up; therefore, complete data were available on 203 women. Overall spontaneous resolution of miscarriage at 2 weeks was observed in 61% (124/203) of women. Rates of spontaneous resolution at 2 weeks according to the type of miscarriage were 71% for incomplete miscarriage, 53% for empty sac and 35% for missed miscarriage. The incidence of unplanned emergency dilatation and curettage due to gynecological infection or hemorrhage was 2.5% (5/203).

CONCLUSIONS

Expectant management based on the 2-week rule is a viable and safe option for women with first-trimester miscarriage. Women with an incomplete miscarriage are apparently the most suitable for expectant management.

Ultrasound evaluation of first trimester pregnancy complications

OBJECTIVE

To review the biological effects and safety of obstetric ultrasound.

OUTCOME

Outline the circumstances in which safety may be a concern with obstetric ultrasound.

EVIDENCE

Medline was searched, and a review of a document on this subject published by Health Canada and of bibliographies from identified articles was conducted.

VALUES

Review by principal authors and the Diagnostic Imaging Committee of the SOGC. The level of evidence was judged as outlined by the Canadian Task Force on the Periodic Health Examination.

BENEFITS, HARMS AND COSTS

Obstetric ultrasound should only be done for medical reasons, and exposure should be kept as low as reasonably achievable (ALARA) because of the potential for tissue heating. Higher energy is of particular concern for pulsed Doppler, colour flow, first trimester ultrasound with a long transvesical path (> 5 cm), second or third trimester exams when bone is in the focal zone, as well as when scanning tissue with minimal perfusion (embryonic) or in patients who are febrile. Operators can minimize risk by limiting dwell time, limiting exposure to critical structures, and following equipment generated exposure information. Recommendations 1. Obstetric ultrasound should only be used when the potential medical benefit outweighs any theoretical or potential risk (II-2A). 2. Obstetric ultrasound should not be used for nonmedical reasons, such as sex determination, producing nonmedical photos or videos, or for commercial purposes ( III-B). 3. Ultrasound exposure should be as low as reasonably achievable (ALARA) because of the potential for tissue heating when the thermal index exceeds 1. Exposure can be reduced through the use of output control and (or) by reducing the amount of time the beam is focused on one place (dwell time) (II-1A). 4. All diagnostic ultrasound devices should comply with the output display standards (MI and TI) (III-B). 5. When ultrasound is done for research or teaching purposes, exposed individuals should be informed if either the MI or TI are greater than 1 and how this exposure compares to that found in normal diagnostic practice (III-B). 6. While imaging the fetus in the first trimester, Doppler and colour Doppler should be avoided (III-B).

Investigation of abnormal first-trimester gestations by color Doppler imaging

Color Doppler imaging was employed to assess the uteroplacental circulation in abnormal first-trimester gestations. Included in the study were 40 blighted ova, 35 missed abortions, 10 trophoblastic diseases, and 3 ectopic gestations. Normal gestations served as a control group. Flow was detected more frequently in the blighted ova than in the missed abortions. Flow was detected in all cases of trophoblastic disease and ectopic gestations. Resistance to flow was significantly lower in the trophoblastic group as compared to the other groups.

The role of ultrasound in the expectant management of early pregnancy loss

OBJECTIVE

To define the sonographic criteria which best determine the likelihood of successful expectant management of early pregnancy failure (EPF).

METHODS

Women with an ultrasound diagnosis of EPF at 7-14 weeks' gestation were offered the option of expectant management or surgical evacuation.

RESULTS

Five hundred and forty-five women had a diagnosis of EPF; 298 with incomplete miscarriage and 247 with missed miscarriage or an embryonic pregnancy. A total of 305 women opted for expectant management, with an overall success rate of 86%. The success rate for incomplete miscarriage (96%) was significantly better than that for missed miscarriage (62%).

CONCLUSION

This study demonstrates that EPF can be safely managed expectantly. Ultrasound has an invaluable role in predicting the likelihood of successful expectant management enabling patients to make an informed choice about their medical care.

Does gestational sac volume predict the outcome of missed miscarriage managed expectantly?

PURPOSE

The aim of this study was to investigate whether gestational sac volume (GSV) can predict the outcome of missed miscarriages that are managed expectantly.

METHODS

This was a prospective observational study. Between February 1, 2000, and January 31, 2001, all patients with a confirmed first-trimester missed miscarriage who chose to undergo expectant management were recruited to participate. A single investigator performed all sonographic examinations and measurements. The main outcome measure was a complete spontaneous abortion within 4 weeks of the initial diagnosis. A complete miscarriage was defined as a maximum anteroposterior diameter of the endometrium of less than 15 mm on transvaginal sonography and no persistent heavy vaginal bleeding. The patients could opt to undergo surgery at any time, but those who had not expelled the products of conception within 4 weeks of the diagnosis were advised to have surgical uterine evacuation.

RESULTS

In total, 90 patients were enrolled, and 86 patients completed the study. The mean GSV, as measured by 3-dimensional sonography, was 9.7 +/- 8.9 ml, and the mean sac diameter was 24.5 +/- 8.0 mm. A significant exponential correlation was found between the mean sac diameter and the GSV (r = 0.86; p < 0.0001). Forty-six (53.5%) of the 86 patients experienced a complete miscarriage within 4 weeks of the diagnosis (ie, expectant management was successful), but expectant management was unsuccessful in the remaining 40 (46.5%) patients (5 had an incomplete miscarriage, and 35 did not expel the products of conception). The GSV did not differ significantly between the "successful" and "unsuccessful" groups (p = 0.82). A logistic regression analysis showed no significant correlation between GSV and the outcome of missed miscarriages managed expectantly (p = 0.59).

CONCLUSIONS

The GSV does not predict the outcome of expectant management of missed miscarriage within 4 weeks of the diagnosis.

Amnion rupture sequence in a first trimester missed abortion

We report the diagnosis of amnion rupture sequence made by sonography and fetoscopy during the first trimester of gestation in a case of missed abortion. The investigation revealed a demised fetus with the characteristics of 9 weeks of development. The early fetus had an amnion adhesion at the tip of the nose and strands of amnion wrapped around the terminal phalanges of both feet. No defects in addition to the face and limb involvement were identified. The karyotype was normal: 46,XX. In the reported case, fetoscopy allowed confirmation of the sonographic diagnosis of an amnion rupture sequence in the first trimester of gestation and consequently helped to clarify the cause of abortion in this case of early fetal demise.

Association between increased yolk sac diameter and abnormal karyotypes

AIMS

To investigate the association between increased yolk sac diameter and abnormal karyotype.

METHODS

Retrospective analysis of 42 patients with no history of diabetes between 6 and 12 weeks of gestation with increased yolk sac diameter measuring ≥6 mm was evaluated by transvaginal ultrasound. Sonographic findings were correlated with karyotype. The Fisher's exact test and exact conditional logistic regression analysis were used for statistical analysis.

RESULTS

Chromosome abnormalities were found in 76.2% of chorionic villi samples. A statistically significant relationship between karyotype and missed abortion was detected (P=0.001). None of the patients with a yolk size diameter ≥8 mm and viable pregnancy had a normal karyotype. Trisomy 15 or 16 was strongly associated with missed abortion (unadjusted odds ratio=14.97, P=0.01). Nine patients with viable pregnancy had a yolk sac ≥6 mm (six patients with normal karyotype, one patient with monosomy X, one patient with trisomy 16, and one patient with trisomy 21).

CONCLUSION

Our data indicate that enlarged yolk sac may also be visualized in viable pregnancies. Patients with an enlarged yolk sac and normal karyotype require detailed ultrasound evaluation in the second and third trimester.