Early Pregnancy Failure Research Articles

Transvaginaler Farbdoppler für die Beurteilung von gynäkologischen Pathologien im kleinen Becken

Transvaginal colour Doppler Sonography was used to assess circulation in pelvic vessels in a group of 611 non-pregnant and 88 pregnant patients. A 5 MHz transvaginal probe was used to visualize the pelvic anatomy and blood flow. Further analysis was made by pulsed Doppler where flow velocity waveforms were recorded and analysed by calculation of resistance index (RI). In the normal flow pattern, the diastolic flow component was absent or small and the value of RI was greater than 0.50. In the abnormal flow pattern, the large diastolic flow component was evident and the value of RI was less than 0.50. The transvaginal colour Doppler assessment of tumour vascularity can be used for better non-invasive characterisation of adnexal tumour and may be potentially useful as a screening test for ovarian malignancy. Because of its high sensitivity, specificity and accuracy, transvaginal colour Doppler Sonography is the imaging of choice, in diagnostic procedure of early pregnancy failure and ectopic pregnancy. The guidance of a pulsed Doppler beam by colour flow mapping helps to locate areas of the most abundant flow and makes examination more reproducible, faster and easier.

Misoprostol for treatment of early pregnancy failure in women with previous uterine surgery

Misoprostol use in early pregnancy may incur a risk of uterine rupture in women with previous uterine surgery. We analyzed 488 women who received misoprostol 800 microg vaginally in a study that evaluated medical and surgical management of early pregnancy failure. Subjects received a repeat misoprostol dose if expulsion was not confirmed 2 days after treatment. We compared efficacy, acceptability, and safety in subjects with a history (n = 78 women) or absence (n = 410 women) of uterine surgery, defined as cesarean delivery or myomectomy. Expulsion rates after a single misoprostol dose (69% vs 72%; P = .64) and overall success at 30 days (82% vs 85%; P = .50) were comparable. Pain, bleeding, complications, and acceptability did not differ. No uterine ruptures occurred (95% CI, 0, 3.8%). Misoprostol treatment for early pregnancy failure had similar success, acceptability, and complications in women with and without previous uterine surgery.

Quality of life and acceptability of medical versus surgical management of early pregnancy failure*

This study compares quality of life (QOL) and acceptability of medical versus surgical treatment of early pregnancy failure (EPF). A randomised clinical trial of treatment for EPF compared misoprostol vaginally versus vacuum aspiration (VA). A multisite trial at four US Urban University Hospitals. A total of 652 women with an EPF were randomised to treatment. Participants completed a daily symptom diary and a questionnaire 2 weeks after treatment. The questionnaire assessment included subscales of the Short Form-36 Health Survey Revised for QOL and measures of wellbeing, recovery difficulties, and treatment acceptability. The two groups did not differ in mean scores for QOL except bodily pain; medical treatment was associated with higher levels of bodily pain than VA (P < 0.001). Success of treatment was not related to QOL, but acceptability of the procedure was decreased for medical therapy if unsuccessful (P = 0.003). Type of treatment was not associated with differences in recovery, and the two groups reported similar acceptability except for cramping (P = 0.02), bleeding (P < 0.001), and symptom duration (P = 0.03). Despite reporting greater pain and lower acceptability of treatment-related symptoms, QOL and treatment acceptability were similar for medical and surgical treatment of EPF. Acceptability, but not QOL, was influenced by success or failure of medical management.

Ultrasonographic Endometrial Thickness After Medical and Surgical Management of Early Pregnancy Failure

We sought to compare endometrial thickness after misoprostol or dilation and curettage (D&C) for early pregnancy failure and to assess the predictive value of endometrial thickness for subsequent D&C after misoprostol treatment. In a randomized trial of early pregnancy failure management, 491 women were treated with misoprostol vaginally, and 161 were treated with D&C. Transvaginal ultrasonography was planned for 2 and 14 days after misoprostol treatment, and 14 days after D&C. The mean endometrial thickness 14 days after treatment was 9.0 mm for the misoprostol group and 6.9 mm for the D&C group, (difference 2.1 mm, 95% confidence interval [CI] 1.0-3.2). After the ultrasonograms 2 and 14 days after misoprostol, 13 (3.8%) and 12 (3.2%) women, respectively, subsequently underwent D&C. Women requiring D&C after successful expulsion had significantly greater endometrial thickness than those who did not at 2 days (mean difference 5.2 mm, 95% CI 1.6-8.8) and 14 days (mean difference 5.5 mm, 95% CI 2.3-8.8) after misoprostol. However, endometrial thickness was a poor predictor of subsequent D&C. The areas under the receiver operating characteristic curves for endometrial thickness at 2 and 14 days were 0.71 and 0.73, respectively. Regardless of cutoff values used for predicting subsequent D&C, endometrial thickness had a positive predictive value of 40% or less. The difference in endometrial thickness between misoprostol treatment and D&C for early pregnancy failure is not clinically significant. Endometrial thickness is not a useful predictor of subsequent surgical intervention after successful expulsion of the gestational sac after misoprostol for early pregnancy failure. ClinicalTrials.gov,www.clinicaltrials.gov, NCT00177333 I.

Evaluation of Early Pregnancy Failure with Ultrasound

Abstract Ultrasound has developed into a powerful tool in the management of early pregnancy failure. However, there is no single finding or measurement that should be used in making a final diagnosis of early pregnancy failure. Instead a combination of clinical, hormonal and ultrasound findings should be used when deciding on the clinical management course.

Fetal rejection: infertility and immunity

Defective reaction toward fetal alloantigens could result in both recurrent spontaneous abortions (RSAs) and recurrent early pregnancy failures (REPFs), the latter existing in couples with unexplained infertility and multiple failures of implantation after in vitro fertilization embryo transfer. Immunological mechanisms leading to RSA and REPF seem to be different, although both syndromes probably have a genetic background that has not been identified so far. Despite the fact that antiphospholipid syndrome is a well-established cause of repeated pregnancy loss, the role of different autoantibodies existing in RSA and REPF patients needs to be elucidated. Immunotherapy is believed to correct the detrimental immune reactions; however, its real effectiveness and safety for the treatment of distinct forms of pregnancy loss need to be reconsidered.

Misoprostol for treatment of early pregnancy failure in women with prior uterine surgery

Misoprostol for treatment of early pregnancy failure in women with prior uterine surgery

Clinical indicators for success of misoprostol treatment after early pregnancy failure

Objective To identify clinical indicators for success of misoprostol treatment after early pregnancy failure. Methods A total of 473 women with early pregnancy failure received 800 μg of vaginal misoprostol on treatment day 1. At the follow-up visit on day 3, a second dose was given if expulsion was incomplete. On day 8, vacuum aspiration was offered if expulsion had not occurred. Ultrasonography was used as gold standard for success. A Classification and Regression Tree analysis was undertaken to derive two decision trees for the success of misoprostol treatment on study days 3 and 8. Results Heavy bleeding after the first dose and an open cervical os were identified as clinical indicators of treatment success on day 3. Treatment success occurred in 84% of women with either or both indicators. Reporting passage of tissue after a second misoprostol dose and old blood in the vagina were potential indicators of treatment success or failure on day 8. A woman with either of these indicators has a 65% chance of treatment success after the second dose. Conversely, a woman with neither indicator on day 8 has a 94% chance of treatment failure. Conclusion Standard clinical findings may be useful as indicators for success or failure of medical management of early pregnancy failure in settings with limited or no access to ultrasonography. More research to identify even better indicators is warranted.

Bleeding Patterns After Misoprostol vs Surgical Treatment of Early Pregnancy Failure: Results from a Randomized Trial

An estimated 900,000 pregnancies fail in the first trimester each year in the US. Traditionally, early pregnancy failure (EPF) has been treated by suction curettage, but prostaglandin analogues such as misoprostol may be an effective and safe alternative to surgery. This randomized trial enrolled 652 women with EPF at a gestational age of 13 weeks or less, who were randomly assigned in a 3:1 ratio to either receive 800 μg of misoprostol, inserted into the posterior vaginal fornix (n =491), or undergo curettage by manual or electric vacuum aspiration (n = 161). All of those taking part in the trial were generally healthy and hemodynamically stable. They kept a diary for 2 weeks and were reassessed on or about day 15. Baseline demographic features and the status of pregnancies were similar in the two treatment groups. Reduction in hemoglobin levels was greater in women given misoprostol than those having curettage (-0.7 gm/dL versus 0.2 gm/dL, P < 0.001). Also noted more often in misoprostol-treated women were a fall in hemoglobin of 2 gm/dL or greater and a nadir hemoglobin level less than 10 gm/dL. More women in the misoprostol group reported any bleeding or heavy bleeding on every day of the 2-week study period. It was not unusual for to continue beyond 2 weeks. Interviews on study 15 indicated that misoprostol recipients viewed as less acceptable than those who bled following curettage. In addition, women given misoprostol were likelier to seek further medical care for bleeding. Greater changes in hemoglobin after misoprostol were independently associated with increasing gestational age, parity, and younger maternal age. Nearly all adverse events related to were noted in women given misoprostol. Fifteen women in this group required curettage, and 4 required blood transfusion. Despite causing more prolonged and heavier than suction curettage in women with EPF, misoprostol remains a safe alternative because intervention for is seldom necessary.

Evidently...

Pregnancy has become highly medicalised over the last century, and is much safer as a result, but we are still learning how best to manage it. Until recently, most early...

Influence of the male on embryo quality

Early pregnancy failure or loss (EPL) represents a major source of wastage and inefficiency in livestock production systems. Although successful embryo development is dependent upon genetic and epigenetic contributions from both the male and female, potential adverse male affects on embryo quality and development are probably often underestimated. Of adverse male effects which have been identified, those associated with sperm and semen “quality” have been best characterized. In turn, although many factors can adversely impact semen quality, the mechanisms involved are relatively few. This presents opportunities for identifying biological markers for spermatogenic damage, as well as protective measures.

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.

Surgical management of early pregnancy failure: history, politics, and safe, cost-effective care

Early pregnancy failure and induced abortion are often managed differently, even though safe uterine evacuation is the goal in both. Early pregnancy failure is commonly treated by curettage in operating room settings in anesthetized patients. Induced abortion is most commonly managed by office vacuum aspiration in awake or sedated patients. Medical evidence does not support routine operating room management of early pregnancy failure. This commentary reviews historical origins of these different care standards, explores political factors responsible for their perpetuation, and uses experience at University of Michigan to dramatize the ways in which history, politics, and biomedicine intersect to produce patient care. The University of Michigan initiated office uterine evacuations for early pregnancy failure treatment. Patients previously went to the operating room. These changes required faculty, staff, and resident education. Our efforts blurred the lines between spontaneous and induced abortion management, improved patient care and better utilized hospital resources.

Transvaginal ultrasound measurement of cervical length and efficacy of misoprostol in first‐trimester pregnancy failure

The aim of this study was to assess the role of cervical length measurement in predicting successful treatment, by misoprostol administration, of early (first-trimester) pregnancy failure. A prospective study was conducted of all patients who agreed to medical treatment of pregnancy failure. Cervical length and other sonographic variables were measured using pelvic ultrasound before medical treatment began. Measurements were compared between the group with successful medical treatment and the group in whom treatment failed. In 125 women included in the study, the success rate of misoprostol treatment was 64.8%. There were no significant differences between the groups with successful and failed treatment for cervical length (29.9 +/- 9.3 vs. 30.4 +/- 6.8 mm, P = 0.75), distance between gestational sac and 'virtual' cervical internal os (23.9 +/- 13 vs. 26.6 +/- 13 mm, P = 0.26), crown-rump length (8.7 +/- 9.7 vs. 6.7 +/- 8.6 mm, P = 0.25), or gestational sac diameter (31.3 +/- 14 vs. 30.1 +/- 15 mm, P = 0.73). Cervical length does not predict the success of misoprostol treatment of first-trimester pregnancy failure.

Medical management of early pregnancy failure in a patient with coronary artery disease

To describe a case of early pregnancy failure in a patient who was not an optimal candidate for suction aspiration because of her body habitus and history of a myocardial infarction that was treated medically with misoprostol. Case report. Academic tertiary-care hospital. A 43-year-old woman with morbid obesity, coronary artery disease, previous myocardial infarction, obstructive sleep apnea, and other medical problems who presented with an early pregnancy failure. Medical management with 800 microg of vaginal misoprostol in an inpatient setting with cardiac monitoring. Ultrasonographic resolution of intrauterine pregnancy, vaginal bleeding, and cardiac events. No gestational sac was visualized by ultrasound on the second hospital day, the patient's hemoglobin value at discharge was 12.1 mg/dL, and no adverse cardiac events occurred. Medical management with misoprostol on an inpatient basis is a possible alternative to dilation and curettage in patients with complex medical problems and early pregnancy failure.

Antioxidant activity of N-acetylcysteine, flavonoids and α-tocopherol on endometrial cells in culture

An appropriate local environment is necessary for successful implantation. Oxidative stress is implicated in the pathogenesis of several pathologies, and may contribute to early pregnancy failure. Antioxidant therapies have been studied in infertility. In this study, we have assessed the antioxidant activity of N-acetylcysteine (NAC), flavonoids (quercetin, catechin) and α-tocopherol in an oxidative model of endometrial cells (RL95). Endometrial cells were incubated at several hydrogen peroxide concentrations. Antioxidant effects of NAC (15 mM), quercetin (150 μM), catechin (150 μM) and α-tocopherol included in liposomes (1.6 μg) were assessed by measuring cell viability by the MTT assay. α-Tocopherol-liposomes taken up by endometrial cells were assessed by HPLC. All liposomes used were able to introduce α-tocopherol into cells. The antioxidant effect of NAC and quercetin improved the viability of oxidised cells, and this effect was observed when the oxidant and antioxidant were coincubated. No viability change occurred when the antioxidant was added before or after the oxidant. The antioxidant effect of NAC was better than that of quercetin. When catechin or α-tocopherol were used in the same conditions, no antioxidant effect was detected in cells in culture. These results demonstrate that NAC and quercetin are good H 2O 2 scavengers.

Biochemistry in the Diagnosis and Management of Abnormal Early Pregnancy

To examine the current state of knowledge regarding the biochemical parameters of early pregnancy failure. Earlier studies have concentrated on the role of human chorionic gonadotropin and progesterone in early pregnancy failure and recent studies have also explored newer markers such as the inhibins and insulin growth factor binding proteins. Multiparameter models have now been created for the prediction of successful expectant management of early pregnancy failure. Examining the role of newer biochemical markers in the early pregnancy failure has led to an improved understanding of the underlying mechanisms and has clinical benefit in the selection of appropriate management for patients.

Contemporary Management of Early Pregnancy Failure

Early pregnancy failure is a common pregnancy complication. This paper reviews the terminology, diagnosis, and treatment of early pregnancy failure. Although surgical curettage has been the standard of care for more than 50 years, additional treatment options exist which appear to be satisfactory to patients. Manual vacuum curettage in the office is an effective alternative to electric vacuum curettage in an operating room. Nonsurgical treatments, including expectant and medical management, are reasonable alternatives depending on the clinical situation and the patient's desires. Clinicians need to understand how these options compare to provide appropriate counseling to patients.

Early serum β-human chorionic gonadotropin in pregnancies after in vitro fertilization: contribution of treatment variables and prediction of long-term pregnancy outcome

Low initial serum beta hCG is a good predictor of early pregnancy failure. We sought to determine the contribution of treatment variables and the predictive value of early serum beta hCG after IVF on long-term pregnancy outcome. A retrospective case-control study. An academic IVF unit. Five hundred thirty-three IVF cycles performed between 1999 and 2004, which resulted in a positive serum beta hCG level (> 10 mIU/mL) on day 13 after embryo transfer (ET). The study group included 281 pregnancies with initial beta hCG < or = 150 mIU/mL on day 13 after ET. Randomly selected 252 IVF cycles with initial beta hCG > 150 mIU/mL comprised the control group. Characteristics of the patients and the treatment protocols were analyzed using logistic regression, Pearson's chi-square, and Fisher's exact test. Primary pregnancy outcome was defined as favorable when a fetal pulse was detected, testifying to a viable gestation. Unfavorable outcome referred to chemical or ectopic pregnancies, as well as spontaneous abortions. Additionally, the two groups were followed throughout gestation. Secondary pregnancy outcome was based on the following parameters: gestational age at delivery, method of delivery, and birth weight. Poor primary pregnancy outcome was encountered in 64.8% of the study group and in 22.2% of the control group. Predictors of unfavorable primary pregnancy outcome were older age, use of a short protocol, and shorter than anticipated crown-rump length. No difference was found in the secondary pregnancy outcome between the groups. Preterm labor was more prevalent in the study group, but the difference did not reach statistical significance. Pregnancy viability can be predicted by measuring serum beta hCG as early as on day 13 after ET. Older age, use of a short protocol, and shorter than anticipated crown-rump length are associated with early pregnancy loss. Of those who reach delivery, no significant adverse outcome is anticipated in IVF pregnancies with low initial serum beta hCG.

Early pregnancy failure induced by dibutyltin dichloride in mice

In this study, we examined the adverse effects of dibutyltin on initiation and maintenance of pregnancy after maternal administration during early pregnancy in mice. Following successful mating, female ICR mice were given dibutyltin dichloride (DBTCl) at 0, 7.6, 15.2, or 30.4 mg/kg bw/day by gastric intubation on days 0-3 or days 4-7 of pregnancy. Female mice were sacrificed on day 18 of pregnancy, and the pregnancy outcome was determined. After administration of DBTCl on days 0-3, the rate of nonpregnant females and the incidence of preimplantation embryonic loss were significantly increased at 30.4 mg/kg bw/day. The incidences of postimplantation embryonic loss in females given DBTCl on days 0-3 at 15.2 mg/kg and higher and on days 4-7 at 7.6 mg/kg bw/day and higher were increased. No increase in the incidence of fetuses with external malformations was observed after the administration of DBTCl on days 0-3 or days 4-7. A decline in the serum progesterone levels was detected in mice given DBTCl at 30.4 mg/kg bw/day on days 0-3 or days 4-7 of pregnancy. The data show that DBTCl adversely affects the initiation and maintenance of pregnancy when administered during early pregnancy in mice and suggest that the decline in serum progesterone levels is responsible for pregnancy failure.