Anembryonic Gestation Research Articles

Tratamiento médico del aborto del primer trimestre: igual eficacia, más eficiencia

BackgroundEarly pregnancy loss occurs in 10-20% of all clinical pregnancies, 85% being prior to week 12 of amenorrhea. Miscarriage entails a very significant burden on healthcare resources, reaching a national economic cost in the United Kingdom of £471 million per year (€533.06 million), a figure that can be extrapolated to other industrialized countries. According to a recent systematic review, there are no well-designed trials in first-trimester pregnancies that provide consolidated evidence on what is the best first-trimester abortion treatment method, and there are different studies that have tried to demonstrate cost reduction with contradictory results. Material and methodsAn observational, retrospective and longitudinal design study was carried out. 892 patients diagnosed with spontaneous abortion during the first trimester of pregnancy were reviewed, in the period between January 2013 and December 2016.In our study, we wanted to evaluate the efficacy of vaginal misoprostol as a medical treatment for spontaneous abortion in the first trimester, in comparison with obstetric curettage-evacuator, and to quantify the difference in the costs of both procedures through a cost minimization study. costs. ResultsOf the 892 recruited patients, medical treatment with misoprostol was performed in 517 (57.95%) and surgical treatment by curettage in 375 (42.05%).The effectiveness of medical treatment was 82% (426/517). With respect to surgical treatment the effectiveness of 100%. The success rate of medical treatment was higher in the subgroup of patients with incomplete abortion (92.9%), compared to the anembryonic gestation (85.7%) and delayed abortion (78.2%) groups. ConclusionsThe medical treatment of abortion is a safe management and accepted by the patients. The adequate selection of candidate patients leads to an increase in the success rate and a decrease in costs. In our study, an important total saving of €576,847.92 (37.14%) with respect to surgical treatment will be reduced. Given that the effectiveness is comparable and patient satisfaction is high, although it could be improved, we believe that with adequate information and homogenization of the applied treatment, it is safe.

ROLE OF TRANSVAGINAL SONOGRAPHY IN FIRST TRIMESTER BLEEDING: A CROSS SECTIONAL STUDY

Introduction: First trimester bleeding has several causes such as Incomplete miscarriage, Hydatiform mole, subchorionic hemorrhage, embryonic mortality, anembryonic pregnancy, failed intrauterine pregnancy, total miscarriage, and ectopic pregnancy. Transvaginal and trans abdominal techniques are used to examine rst-trimester hemorrhage, transvaginal being preferred & better method. To evaluate Aims and objectives: various causes of rst trimester bleeding and role of TVS in rst trimester bleeding. This cross-sectional study was Material And Methods: conducted on 50 patients in the Department of Radiodiagnosis at Rajshree Medical Research Institute, Bareilly, Uttar Pradesh from1st February 2021 to 31st July 2022. Majority of participants were aged 19–25yrs (56.0%).USG Diagnosis showed Results: Threatened abortion among 36.0%,Incomplete abortion among 22.0%, Complete abortion among 12.0%, Missed abortion among 8.0%,Ectopic gestation among 8.0%, Inevitable abortion among 6.0%,Anembryonic gestation among 4.0% and Hydatidiform mole among 4.0%.There was complete concordance between USG and Final Diagnosis.

P-351 Medical treatment for missed abortion- difference in gestational age based on menstrual dating and on ultrasound criteria, and the correlation to failure

Abstract Study question Does the difference in gestational age based on menstrual dating and on ultrasound criteria correlate with failure rate of medical treatment in missed abortions? Summary answer In missed abortions, the difference in gestational age based on menstrual dating and on ultrasound is inversely correlated with failure rate of medical treatment. What is known already A number of factors have been reported as predictors for Misoprostol treatment failure, including assisted reproductive treatment, primigravity, and vaginal bleeding prior to treatment. Increased rates of failure with medical management were also reported with delaying treatment after diagnosis. Study design, size, duration This was a retrospective cohort study. Overall, 778 patients who underwent medical treatment with Misoprostol for missed abortion at our institute, between 07/2015 and 12/2020 were included. Participants/materials, setting, methods Inclusion criteria were either anembryonic gestation or embryonic death, as long as pregnancy age, as measured by transvaginal sonography , correlated with 12 weeks gestation or less. Exclusion criteria included incomplete or septic abortions, multiple pregnancies, and cases that had either irregular period, missing data, or were lost to follow up. The primary outcome was treatment failure, defined as any need for surgical intervention (elective or emergency Dilation & curettage, or operative hysteroscopy). Main results and the role of chance Five hundred and eighty two patients (74.9%) had successful medical treatment, while 196 (25.1%) required surgical intervention. The gestational age based on menstrual dating and on ultrasound difference (in weeks) was 2.6±1.4 in the success group and 3.1±1.6 in the failure group (p < 0.001). On multivariant regression analysis, gestational age based on menstrual dating and on ultrasound difference was found to be independently correlated with treatment failure (aOR=1.24, CI 95% (1.01-1.51), p = 0.03). Limitations, reasons for caution We did not analyze long term consequences, such as the amount of bleeding, and time to future fertility. Moreover, patients who were treated at our institute may have been diagnosed and treated for treatment failure in neighboring hospitals and hence lost to follow-up. Wider implications of the findings The current study has shown that the difference between gestational age based on menstrual dating and on ultrasound is directly corelated with medical treatment failure. This data should be taken into account when counseling patients regarding the optimal treatment for first trimester missed abortion. Trial registration number not applicable

Early Pregnancy Failure: Medical versus Surgical Management

Introduction: Misoprostol is increasingly used to treat women who have a failed pregnancy may be due to blighted ovum (anembryonic gestation), incomplete abortion, missed abortion, inevitable abortion in the first trimester. Medical treatment with Misoprostol is an alternative to conventional surgical treatment. Use of Misoprostol is simple, highly acceptable, noninvasive and preferred by women. In addition to surgical risk and patient's preference, medical evacuation reduces the need for hospital stay and the overall management cost. Objective: To determine the efficacy and safety of Misoprostol for evacuation of uterus in early pregnancy loss and to compare the result with surgical evacuation. Materials and Methods: It was a prospective randomized study conducted on 50 patients at the department of Obstetrics and Gynaecology, Border Guard Hospital, Dhaka during the period from February 2018 to July 2019. Here 25 patients received Misoprostol as medical treatment and 25 patients received surgical treatment. Results: Of the 25 women assigned to receive Misoprostol, 19(76%) had complete expulsion by 24 hours and 22(88%) by 7 days. Complete evacuation after 1st dose was 68% and after 2nd dose 88%. Misoprostol treatment failed in 3(12%) cases and required surgical evacuation. Among the respondents 80% women stated that they would use Misoprostol again if the need arises. Conclusion: Medical treatment with Misoprostol is a cheaper alternative to surgery. Given its success rate near about 88% with mild side effects controllable with additional medication and above all patient’s satisfaction, it should be prioritized over the evacuation curettage in patients who meet the treatment criteria. JAFMC Bangladesh. Vol 16, No 2 (December) 2020: 63-67

COMPARISON OF MIFEPRISTONE (200mg) FOLLOWED BY MISOPROSTOL (800µg) 6 HRS LATER WITH 24 HRS LATER IN EARLY PREGNANCY FAILURE

INTRODUCTION: Early pregnancy failure (EPF) is an inclusive term that comprises incomplete, complete, or inevitable spontaneous abortion; anembryonic gestation (blighted ovum); and embryonic demise (missed abortion) at less than 14 weeks 1. It is one of the most common complications of pregnancy, accounting for approximately 15% to 20% of clinically recognized pregnancies 1,2. Many EPFs occur before pregnancies have been clinically recognized (that is, women mistake them for “late cycles”). AIMS & OBJECTIVES: To compare the efcacy between mifepristone 200mg orally followed by misoprostol 800µg vaginally 6 hrs later with mifepristone 200mg orally followed by misoprostol 800µg vaginally 24 hrs later in early pregnancy failure for termination up to 9 weeks of gestation. To reduce unusual blood loss. To reduce surgical intervention in case of early pregnancy failure. MATERIALS & METHODS: Hospital based Prospective randomiSe comparative single centre study. Department of Obstetrics and Gynecology Midnapore Medical College and Hospital. One year from January 2019 to February 2020 for data collection and six month for data analysis. Mother attended the Gynae OPD clinic and Obstetrics emergency with features of early pregnancy failure. The sample size was 50, with 25 patients in each group. RESULTS:We found that the table 4 shows the distribution according to gestational age. The main indication for which medical abortion was done in our study is early pregnancy failure (Blighted ovum) and missed abortion. Majority of patients were in the gestational age between 8-9 weeks with 48 % of women who underwent 6 hour interval regimen and 40% of women who underwent 24 hour interval regimen. P value documented is 0.849 which is not signicant. There was no signicant difference between two groups regarding gestational age (p value=0.849). SUMMARY AND CONCLUSION: Vaginal Misoprostol can be safely administered 6 hours following Mifepristone instead of waiting for 24 hours. Efcacy in achieving complete abortion rate is almost equal to 24 hours regimen and most acceptable from patient's side also. Additionally, women are less likely to experience side effects the earlier the misoprostol is used. Women can now have more exibility when using mifepristone and vaginal misoprostol for medical abortion

Should All Abortion Materials Be Sent for Histopathological Evaluation?

Objective: Partial hydatidiform mole is the type of mole in which a foetus and/or cardiac activity is seen. Clinical diagnosis of missed abortion and anembryonic gestation may cause the partial mole to be missed or misdiagnosed if a histopathologic examination is not carried out. Our objective in this study was to clarify whether it is really necessary to send all abortion materials for histopathological examination considering the rate of mole (complete/partial) among all abortion materials in a university hospital. Material and Methods: In this retrospective cohort study, we evaluated the clinical and histopathological results of 1,004 women with a clinical diagnosis of abortion that were diagnosed at the University of Kütahya Health Sciences Evliya Çelebi Hospital between January 2015 and December 2020. Results: Missed abortion was the most common diagnosis with 638 women (63.5%) among the abortion materials that were sent for histopathology. Complete mole was diagnosed in only one (1/1,004) woman, which was sent to pathology with a diagnosis of anembryonic gestation. The partial mole rate was 9/1,004 and most were diagnosed after a clinical diagnosis of anembryonic gestation (n=5, 55%). Placental villi were seen in 93% (934/1,004) but not in 6% (60/1,004) of the subjects (Arias-Stella reaction) on histopathology, which was possibly an ectopic pregnancy or a very early aborted early gestation in which placenta villi could not be identified. Partial and complete mole hydatidiform constituted 1% (9/1,004) and 0.1% (1,004) of the total cohort respectively. Conclusion: When taking into account the rate of mole hydatidiform (10/1,004) in a clinic where all abortion materials are being sent for histopathological examination routinely, we think that routine histopathological examination of abortion material seems reasonable and safe.

Cost-effectiveness of Mifepristone Pretreatment for the Medical Management of Nonviable Early Pregnancy

Early pregnancy loss (EPL) is the most common complication of pregnancy. A multicenter randomized clinical trial compared 2 strategies for medical management and found that mifepristone pretreatment is 25% more effective than the standard of care, misoprostol alone. The cost of mifepristone may be a barrier to implementation of the regimen. To assess the cost-effectiveness of medical management of EPL with mifepristone pretreatment plus misoprostol vs misoprostol alone in the United States. This preplanned. prospective economic evaluation was performed concurrently with a randomized clinical trial in 3 US sites from May 1, 2014, through April 30, 2017. Participants included 300 women with anembryonic gestation or embryonic or fetal demise. Cost-effectiveness was computed from the health care sector and societal perspectives, with a 30-day time horizon. Data were analyzed from July 1, 2018, to July 3, 2019. Mifepristone pretreatment plus misoprostol administration vs misoprostol alone. Costs in 2018 US dollars, effectiveness in quality-adjusted life-years (QALYs), and treatment efficacy. Incremental cost-effectiveness ratios (ICERs) of mifepristone and misoprostol vs misoprostol alone were calculated, and cost-effectiveness acceptability curves were generated. Among the 300 women included in the randomized clinical trial (mean [SD] age, 30.4 [6.2] years), mean costs were similar for groups receiving mifepristone pretreatment and misoprostol alone from the health care sector perspective ($696.75 [95% CI, $591.88-$801.62] vs $690.88 [95% CI, $562.38-$819.38]; P = .94) and the societal perspective ($3846.30 [95% CI, $2783.01-$4909.58] vs $4845.62 [95% CI, $3186.84-$6504.41]; P = .32). The mifepristone pretreatment group had higher QALYs (0.0820 [95% CI, 0.0815-0.0825] vs 0.0806 [95% CI, 0.0800-0.0812]; P = .001) and a higher completion rate after first treatment (83.8% vs 67.1%; P < .001) than the group receiving misoprostol alone. From the health care sector perspective, mifepristone pretreatment was cost-effective relative to misoprostol alone with an ICER of $4225.43 (95% CI, -$195 053.30 to $367 625.10) per QALY gained. From the societal perspective, mifepristone pretreatment dominated misoprostol alone (95% CI, -$5 111 629 to $1 801 384). The probabilities that mifepristone pretreatment was cost-effective compared with misoprostol alone at a willingness-to-pay of $150 000 per QALY gained from the health care sector and societal perspectives were approximately 90% and 80%, respectively. This study found that medical management of EPL with mifepristone pretreatment was cost-effective when compared with misoprostol alone. ClinicalTrials.gov Identifier: NCT02012491.

THE PRACTICAL IMPORTANCE OF LABORATORY TEST FOR HEREDITARY PREDISPOSITION TO THE FOLATE CYCLE VIOLATIONS

Hereditary predisposition is a risk factor for human diseases at different age, including embryonic and fetal periods. One of the indicators of hereditary predisposition may be the presence of polymorphic alleles of the folate cycle enzymes genes.Objective: to develop an algorithm for the prevention of gestational complications, diseases of the newborn by determining the alleles of the folate cycle enzymes genes of biological parents’ organisms, the newborn, and the use of personalized preventive measures.Materials and methods. 100 women and 50 men of the reproductive age have been examined. Group I and Group Ia underwentthe proposed preconception preparation. 100 newborns from women of both groups have been examined. The folate cycle enzymes genes alleles were studied in people of 20 families, the women of which had pregnancy with placental dysfunction, premature detachment of the placenta, the fetal growth retardation syndrome, congenital malformations of the fetus.Results and its discussion. Among women, methylenetetrahydrofalatreductase polymorphism on T allele was detected in 63 (63.0 %) cases: homozygous – in 18 (18.0 %), heterozygous – in 45 (45.0 %); among men correspondingly – in 31 (62.0 %), 11 (22.0 %), 21 (42.0 %) cases. Among newborns, methylenetetrahydrofalatereductase polymorphism on T allele was detected in 65 (65.0 %) cases: homozygous – in 20 (20.0 %), heterozygous – in 45 (45.0 %). The women who underwent the proposed preconception preparation had the significantly reduced 5.2 times frequency of miscarriage threat syndrome, subchorionic hematoma – 7 times. Anembryonic gestation, gestational pyelonephritis, congenital malformations of the fetus, anemia of pregnant women, premature labor, placental dysfunction by the gestation trimesters in the main group were not observed, which confirms the effectiveness of the preparation.Conclusion. The presence of polymorphic alleles of the folate cycle enzymes genes is a risk factor for diseases of the cardiovascular, digestive, urinary, reproductive systems, reproductive disorders, confirms a necessity in a personalized algorithm for preconception preparation and personalized prevention of gestational complications, diseases in children.

Mifepristone Pretreatment for the Medical Management of Early Pregnancy Loss

BackgroundMedical management of early pregnancy loss is an alternative to uterine aspiration, but standard medical treatment with misoprostol commonly results in treatment failure. We compared the efficacy and safety of pretreatment with mifepristone followed by treatment with misoprostol with the efficacy and safety of misoprostol use alone for the management of early pregnancy loss.MethodsWe randomly assigned 300 women who had an anembryonic gestation or in whom embryonic or fetal death was confirmed to receive pretreatment with 200 mg of mifepristone, administered orally, followed by 800 μg of misoprostol, administered vaginally (mifepristone-pretreatment group), or 800 μg of misoprostol alone, administered vaginally (misoprostol-alone group). Participants returned 1 to 4 days after misoprostol use for evaluation, including ultrasound examination, by an investigator who was unaware of the treatment-group assignments. Women in whom the gestational sac was not expelled were offered expectant management, a second dose of misoprostol, or uterine aspiration. We followed all participants for 30 days after randomization. Our primary outcome was gestational sac expulsion with one dose of misoprostol by the first follow-up visit and no additional intervention within 30 days after treatment.ResultsComplete expulsion after one dose of misoprostol occurred in 124 of 148 women (83.8%; 95% confidence interval [CI], 76.8 to 89.3) in the mifepristone-pretreatment group and in 100 of 149 women (67.1%; 95% CI, 59.0 to 74.6) in the misoprostol-alone group (relative risk, 1.25; 95% CI, 1.09 to 1.43). Uterine aspiration was performed less frequently in the mifepristone-pretreatment group than in the misoprostol-alone group (8.8% vs. 23.5%; relative risk, 0.37; 95% CI, 0.21 to 0.68). Bleeding that resulted in blood transfusion occurred in 2.0% of the women in the mifepristone-pretreatment group and in 0.7% of the women in the misoprostol-alone group (P=0.31); pelvic infection was diagnosed in 1.3% of the women in each group.ConclusionsPretreatment with mifepristone followed by treatment with misoprostol resulted in a higher likelihood of successful management of first-trimester pregnancy loss than treatment with misoprostol alone. (Funded by the National Institute of Child Health and Human Development; PreFaiR ClinicalTrials.gov number, NCT02012491.)

Treatment Decisions at the Time of Miscarriage Diagnosis.

To describe the factors patients and physicians prioritize during first-trimester miscarriage management and assess what drives satisfaction with care. We conducted a mixed-methods study of clinically stable women seeking surgical, medical, or expectant miscarriage treatment. Women with first-trimester fetal demise or anembryonic gestation (N=55) completed demographic and psychosocial surveys. Using purposive sampling, 45 (82%) completed in-depth interviews. Fifteen obstetricians were interviewed. Participants described factors that informed their counseling (physicians) or decision-making (patients). Content analysis used an integrated approach with inductively and deductively derived codes. Patient-derived themes were stratified by treatment choice. Associations between variables and treatment choices were analyzed. Thirty-four women (62%) received surgical management, 19 (35%) received medical, and two (4%) received expectant. Physicians expected that women with prior pregnancies have strong management preferences, and indeed, multigravid patients were less likely to change their initial treatment choice after counseling than primigravid patients (12% compared with 42%, odds ratio [OR] 0.18, 95% confidence interval [CI] 0.04-0.81, P=.03). Physicians favored patient-centered decisions and patients chose the treatment that they thought would least affect other responsibilities. Those ultimately receiving surgical management had a higher monthly income (adjusted OR 1.30, 95% CI 1.04-1.63, P=.023) and more social support (adjusted OR 2.45, 95% CI 1.07-5.61, P=.035) than the medical group. The surgical group cited loss acceptance, a favorable perception of surgery, and a desire to expedite the miscarriage as decisive factors. The medical group endorsed control over, and timed completion of, the miscarriage in a more intimate setting, an aversion to surgery or anesthesia, and a perception of improved fertility preservation as decisive factors. Regardless of treatment choice, satisfaction with treatment was linked to a supportive clinical team and expeditious resolution. Prior pregnancy experiences, obligations, and sociodemographic factors influence miscarriage management decision-making. Structured counseling, especially for primigravid patients, could improve both the physician and the patient experience with miscarriage care.

Missed abortion: anembrionia and normal karyotype of chorion

The most probable cause of an anembryonic gestation is an abnormal karyotype. The analysis of 59 cases of missed abortion with anembrionia prior to 12 weeks of gestation after spontaneous conception and the assisted reproductive technologies (ART) was carried out. Patients were divided into two groups: those pregnant after natural conception and those with pregnancies after the ART programs. Upon embryoscopy and direct chorion biopsy, samples were sent for karyotyping. High frequency of normal karyotypes of chorion was found: 28.6% and 44.7%, respectively.

Medical Treatment of Spontaneous Abortion in the First Trimester

Background: The objective was to evaluate the efficacy of medical treatment with misoprostol in spontaneous abortion in the first trimester. The other objectives were to determine the incidence of side effects and complications and identify causes that may motivate medical treatment failure, and to establish the degree of acceptance and patient satisfaction. A cost-effectiveness study was performed. Methods: It was longitudinal, observational, prospective, descriptive and analytic research. We evaluated 680 patients diagnosed with spontaneous abortion of the first trimester, in the period between June 2009 and December 2011 at the Hospital Clinico San Carlos. It was developed a protocol for the administration of medical treatment with misoprostol for those patients who accepted, compared with classic surgery. Results: The success of medical treatment was 81.85%, it was effective in 89.21% of accomplished incomplete abortion, in the 79.52% of deferred abortion and in the 78.46% of anembryonic gestation. There were minor side effects in the 33.59% of patients, declaring satisfaction in 84.99% of patients. With regard to cost study, there was a patient savings €960.54. Conclusions: The success of medical treatment in our study was high, with effective approximately eight out of 10 patients. Misoprostol is highly accepted by patients, declaring most satisfied. The incidence of minor side effects is low, and were well tolerated, so their presence does not seem to restrict the application of such treatment. Its use helps to reduce healthcare costs. J Clin Gynecol Obstet. 2015;4(3):265-270 doi: http://dx.doi.org/10.14740/jcgo335w

Medical management of early pregnancy failure (EPF): a retrospective analysis of a combined protocol of mifepristone and misoprostol used in clinical practice

To evaluate the efficacy of a combined protocol of mifepristone and misoprostol in the management of early pregnancy failure (EPF) and the average time to expulsion of tissue and rate of side effects. Retrospective chart review of all consecutive women treated with primary medical management for EPF at our institution from 2006 to 2012. 168 patients were included in the present study. The overall success rate, defined as the absence of the need for surgical intervention, was 61 % and did not differ by calendar year. There was no difference in success rate grouped by diagnosis [intrauterine embryonic/fetal demise (IUED/IUFD) vs. anembryonic gestation; p = 0.30] or gestational age (<9 or ≥9 weeks; p = 0.48). The success rate varied significantly according to the required dose of misoprostol, ≤800 or >800 μg (68 vs. 50 %, p = 0.029). Of the possible predictive factors of success, only the dose of misoprostol required was a significant independent negative predictor. Mean and median time to tissue expulsion after the first dose of misoprostol were 8.4 and 5.5 h, respectively. The incidence of side effects was low with no blood transfusions required. The success rate in this study is markedly below published data. This can possibly be attributed to retrospective study design, allowing for physician subjectivity and patients' wishes in the absence of strict study requirements. The protocol was well tolerated with a paucity of side effects. We make suggestions for enhancing success rates in the clinical setting by optimizing medication protocols, establishing precise treatment guidelines and training physicians in the accurate interpretation of treatment outcomes.

Inflammatory Pseudotumor of the Kidney

First trimester bleeding is a common presentation in the emergency room. Ultrasound evaluation of patients with first trimester bleeding is the mainstay of the examination. The important causes of first trimester bleeding include spontaneous abortion, ectopic pregnancy, and gestational trophoblastic disease; 50% to 70% of spontaneous abortions are due to genetic abnormalities. In normal pregnancy, the serum beta hCG doubles or increases by at least 66% in 48 hours. The intrauterine GS should be visualized by TVUS with beta hCG levels between 1000 to 2000 mIU/mL IRP. Visualization of the yolk sac within the gestational sac is definitive evidence of intrauterine pregnancy. Embryonic cardiac activity can be identified with CRL of >5 mm. A GS with a mean sac diameter (MSD) of 8 mm or more without a yolk sac and a GS with an MSD of 16 mm or more without an embryo, are important predictors of a nonviable gestation. A GS with a mean sac diameter of 16 mm or more (TVUS) without an embryo is a sonographic sign of anembryonic gestation. A difference of <5 mm between the mean sac diameter and the CRL carries an 80% risk of spontaneous abortion. Approximately 20% of women with first trimester bleeding have a subchorionic hematoma. The presence of an extra ovarian adnexal mass is the most common sonographic finding in ectopic pregnancy. Other findings include the tubal ring sign and hemorrhage. About 26% of ectopic pregnancies have normal pelvic sonograms on TVUS. Complete hydatidiform mole presents with a complex intrauterine mass with multiple anechoic areas of varying sizes (Snowstorm appearance). Twenty-five percent to 65% of molar pregnancies have associated theca-leutin cysts. Arteriovenous malformation of the uterus is a rare but life-threatening cause of vaginal bleeding in the first trimester. The sonographic findings in a patient with first trimester bleeding should be correlated with serum beta hCG levels to arrive at an appropriate clinical diagnosis.

Medical management of first trimester miscarriage according to ultrasonographic findings

The efficacy of medical treatment of first trimester miscarriages may depend on the regimen used, the definition of success, clinical symptoms, and, possibly, on the ultrasonographic findings. Our primary aim was to assess if a single dose of misoprostol could reduce the number of surgical interventions in early pregnancy failure, and to compare efficacy in different ultrasonographically-defined subgroups. A retrospective review of 355 consecutive patients treated for a first trimester miscarriage with a single dose of vaginal misoprostol (400 microg), followed by vaginal ultrasonography after either 1, 2 or 3 days. Treatment was successful if a complete abortion was diagnosed at follow-up. The women were divided into 4 ultrasonographically-defined groups: missed abortion with a crown rump length (CRL)>or=6 mm (Group A1) or CRL<6 mm (Group A2), anembryonic gestation with gestational sac>or=18 mm (Group B1) or <18 mm (Group B2). The overall success rate was 39.2% (139/355). The regimen was more efficacious in Group A2 (50%) and less efficacious in Group B1 (26.6%) than in the other groups. The success rates were lower 1 day after treatment (30.2%) compared to days 2 and 3 (43.6%; p<0.05), and the difference was largest in Group B1 (12.9 versus 35.4%; p<0.05). Single dose misoprostol reduced the number of surgical interventions. The success rates of medically-treated first trimester miscarriages varied according to the ultrasonographic definitions of pregnancy failure, time of assessment, and the criteria for success.

Recurrent spontaneous abortion and skewed X-inactivation: is there an association?

The purpose of this study was to determine whether there is an association between skewed X-inactivation and recurrent spontaneous abortion in a large, well-defined sample of women with recurrent loss. X-chromosome inactivation patterns were compared in 5 groups of women. Group 1 (recurrent spontaneous abortion) consisted of 357 women with 2 or more spontaneous losses. In group 2 (infertility), there were 349 subjects from infertility practices recruited at the time of a positive serum beta-human chorionic gonadotropin. Group 3 (spontaneous abortion) women (n = 81) were recruited at the time of an ultrasound diagnosis of an embryonic demise or an anembryonic gestation. Groups 4 (primiparous) and 5 (multiparous) were healthy pregnant subjects previously enrolled in another study to determine the incidence and cause of pregnancy complications, such as preeclampsia and intrauterine growth restriction. The Primiparous group included 114 women in their first pregnancy, whereas the Multiparous group consisted of 79 women with 2 or more pregnancies but without pregnancy loss. The rate of extreme skewing (90% or greater) in the recurrent spontaneous abortion population was 8.6%, and not statistically different from any of the other groups, except the Primiparous group (1.0%, P < .01). The incidence of X-inactivation skewing of 90% or greater was no different whether there had been at least 1 live birth (9.9%), or no previous live births and at least 3 losses (5.6%, P > .05). When age and skewing of 90% or greater are compared, subjects with extreme skewing have a mean age of 2 years older than those without extreme skewing (P < .05). Skewed X-inactivation is not associated with recurrent spontaneous abortion but is associated with increasing maternal age.

Free fetal DNA in maternal plasma in anembryonic pregnancies: confirmation that the origin is the trophoblast

To test the hypothesis that free fetal DNA (ffDNA) circulating in maternal plasma originates mainly from the placenta we studied ffDNA levels in anembryonic pregnancies. Maternal blood samples were collected from 15 normal first-trimester pregnancies in which fetal sex was subsequently determined and nine patients with a diagnosis of anembryonic gestation (AG). The Y chromosome DYS14 gene was quantified by real-time quantitative PCR (RT-PCR) for the determination of fetal sex in both plasma and chorionic tissue samples. Fetal sex in chorionic tissue samples was also determined using quantitative fluorescence PCR (QF-PCR). The correct sex result was obtained from maternal plasma in all. Four AG pregnancies were female (DYS14 negative) results. In five of the AG cases, the chorionic tissue was found to be male (by both QF-PCR and RT-PCR which agreed) and positive male signal was found in maternal plasma by RT-PCR. There was no statistical difference between median free fetal DNA concentration in plasma between the AG male cases (148.3 GE/mL) and controls (145.8 GE/mL). Since ffDNA levels are normal in pregnancies without a fetus, the data support the hypothesis that the trophoblastic cells are the major source ffDNA in maternal plasma.

A Comparison of Medical Management with Misoprostol and Surgical Management for Early Pregnancy Failure

An estimated 15% of clinically apparent pregnancies are complicated by early pregnancy failure, most commonly in the form of spontaneous abortion, anembryonic gestation, or embryonic or fetal death. Approximately one of every 4 women will experience an early pregnancy failure. Expectant management is an option for incomplete spontaneous abortion, but frequently fails when used for embryonic or fetal death or anembryonic gestation. Misoprostol has become an increasingly favored treatment because it evacuates the uterus more promptly. This randomized trial, conducted at several centers, compared misoprostol treatment with vacuum aspiration in 652 women with first-trimester pregnancy failure. They were randomly assigned, in a 3:1 ratio, to receive 800 μg misoprostol vaginally or to undergo vacuum aspiration. Misoprostol was given on day 1 and followed by a second dose on day 3 if expulsion was not complete. Vacuum extraction was done on day 8 if expulsion remained incomplete. Treatment was considered to have failed if a misoprostol-treated patient required surgery or if vacuum aspiration was repeated within 30 days. The most common form of early pregnancy failure, present in 58% of cases, was embryonic or fetal death, and the next most common, occurring in 36% of cases, was anembryonic gestation. Gestational age averaged 7.6 weeks. In women who completed the trial, success rates were 84% for those given misoprostol and 97% in those having vacuum aspiration. In misoprostol-treated women, products of conception were expelled entirely after a single dose in 71% of cases. A second dose was effective in 60% of cases when needed, for an overall success rate by day 8 of 84%. Success rates were lowest when there was an anembryonic gestation. In neither treatment group was the success rate related to gestational age at the time of treatment. Hemorrhage and pelvic infection were rare in both groups. Decreased hemoglobin was more frequent in misoprostol-treated women and they also were likelier to report nausea, vomiting, abdominal pain, and more severe pain. Nevertheless, 83% would recommend misoprostol treatment and 78% would probably or definitely have it again if necessary. Misoprostol, administered vaginally, is an effective and safe means of managing early pregnancy failure.

A Comparison of Medical Management with Misoprostol and Surgical Management for Early Pregnancy Failure

Misoprostol is increasingly used to treat women who have a failed pregnancy in the first trimester. We assessed the efficacy, safety, and acceptability of this treatment in a large, randomized trial. A total of 652 women with a first-trimester pregnancy failure (anembryonic gestation, embryonic or fetal death, or incomplete or inevitable spontaneous abortion) were randomly assigned to receive 800 microg of misoprostol vaginally or to undergo vacuum aspiration (standard of care) in a 3:1 ratio. The misoprostol group received treatment on day 1, a second dose on day 3 if expulsion was incomplete, and vacuum aspiration on day 8 if expulsion was still incomplete. Surgical treatment (for the misoprostol group) or repeated aspiration (for the vacuum-aspiration group) within 30 days after the initial treatment constituted treatment failure. Of the 491 women assigned to receive misoprostol, 71 percent had complete expulsion by day 3 and 84 percent by day 8 (95 percent confidence interval, 81 to 87 percent). Treatment failed in 16 percent of the misoprostol group and 3 percent of the surgical group (absolute difference, 12 percent; 95 percent confidence interval, 9 to 16 percent) by day 30. Hemorrhage or endometritis requiring hospitalization was rare (1 percent or less in each group), with no significant differences between the groups. In the misoprostol group, 78 percent of the women stated that they would use misoprostol again if the need arose and 83 percent stated that they would recommend it to others. Treatment of early pregnancy failure with 800 microg of misoprostol vaginally is a safe and acceptable approach, with a success rate of approximately 84 percent.

Pitfalls in First Trimester Ultrasound

Sonographic evaluation in the first trimester of pregnancy almost always is performed using the transvaginal approach. The increased resolution afforded by this technique has made it possible to detect early embryologic events that can cause problems in interpretation by the general radiologist. To comprehend abnormal ultrasound findings in early pregnancy and avoid potential pitfalls of misdiagnosis, it is important to understand normal physiologic and anatomic changes during embryologic and fetal development.1 These potential pitfalls can be classified into five categories: anembryonic gestation, ectopic pregnancy, physiologic umbilical herniation, nuchal translucency, and open rhombencephalon.