Vaginal Bleeding In Early Pregnancy Research Articles

A rapid improvement event: progesterone prescribing in prevention of miscarriage

A rapid improvement event (RIE) is a standard operational excellence technique that uses team-based problem solving to improve processes. In this study, a RIE was undertaken to improve progesterone prescribing...

P-546 History of caesarean births and risk of miscarriage - secondary analysis of three randomised controlled trials

Abstract Study question Does the history of caesarean births influence miscarriage risk in subsequent pregnancies? Summary answer In women with a history of 3 or more miscarriage(s), the subsequent miscarriage risk may increase with the presence and number of previous caesarean births. What is known already History of caesarean birth increases the risk of complications in subsequent pregnancies, including risks of spontaneous preterm birth. The evidence of association between caesarean births and subsequent miscarriage risk is scant and conflicting. Study design, size, duration We performed a secondary analysis of the dataset from three multicentre, prospective, double-blind, and placebo-controlled randomized trials. Study registration, duration, size, population, and intervention are as follows: 1) PROMISE; ISRCTN92644181; 2010 - 2013, 826 women with a history of unexplained recurrent miscarriages, progesterone. 2) PRISM; ISRCTN14163439; 2015 - 2017, 4038 women who experienced vaginal bleeding in early pregnancy, progesterone. 3) TABLET; ISRCTN15948785; 2011 - 2016, 940 euthyroid women with thyroid peroxidase antibodies, and miscarriages or infertility history, levothyroxine. Participants/materials, setting, methods The primary outcome for this analysis was miscarriage rate, defined as loss of pregnancy <24 weeks of gestation. RR with 95% CI was estimated using the Poisson regression model and adjusted for age, BMI, ethnicity, smoking status, and previous miscarriages. Random-effects two-stage individual participant data meta-analysis approach was used to account for treatment allocation effects. Subgroup analysis was conducted in women with a history of repeated miscarriages (3 or more) at randomisation. Main results and the role of chance After excluding pregnancies with incomplete data, we included 5,039 pregnancies in the final analysis. The overall miscarriage rate was 24.9% (1256/5039). In the non-specific population of women, there was no association between the history of caesarean births and subsequent miscarriage risk (aRR 1.00, 95% CI 0.86 to 1.17; 5,039 pregnancies). In contrast, for the subgroup of women with a history of 3 or more miscarriage(s) at randomisation, the miscarriage rate appears to increase with the history of caesarean births, although with some degree of statistical uncertainty (aRR 1.10, 95% CI 0.97 to 1.26; 1172 pregnancies). The association became significant when the analysis was categorised according to the number of previous caesarean births. With 1 previous caesarean birth, the miscarriage risk increased by 3% (aRR 1.03, 95% CI 1.00 to 1.06; 1080 pregnancies). This risk was increased by 37% with 2 previous caesarean births (aRR 1.37, 95% CI 1.03 to 1.83; 971 pregnancies), therefore indicating the presence of a biological gradient of effect which increases our confidence in the above findings. The history of previous caesarean births may be a valid prognostic risk factor for future miscarriage risk in women with a history of recurrent miscarriage. Limitations, reasons for caution Further analysis by the gestation at miscarriage (early vs. late), the type (elective vs. emergency), indication or cervical dilatation status at caesarean births is required to understand the possible mechanism behind this association and to better identify women at increased risk of miscarriage(s) related to caesarean births. Wider implications of the findings Our findings suggest that a history of caesarean births may be associated with a small increased risk of subsequent miscarriage risk in a subgroup of women with a history of recurrent miscarriage(s). This information may assist women and healthcare providers to reach more informed decisions regarding the mode of delivery. Trial registration number The study is registered with the OSF registry (ve5j4).

Analysis of incidence and associated factors of preterm birth based on pre-pregnancy body mass index stratification

Objective: To analyze the incidence of preterm birth based on pre-pregnancy body mass index (BMI) stratification and explore the associated factors of preterm birth among pregnant women at different BMI stratifications. Methods: From February 2018 to December 2020, pregnant women who participated in China Birth Cohort Study (CBCS) and gave birth at Beijing Obstetrics and Gynecology Hospital were enrolled as the study subjects. Electronic Data Capture System and standard structured questionnaires were used to collect data related to pre-pregnancy, pregnancy, and delivery for pregnant women. Pregnant women were divided into the low-weight group, normal-weight group and overweight group based on their pre-pregnancy BMI. A Cox proportional hazards model was used to analyze the associated factors of preterm birth among pregnant women with different BMI before pregnancy. Results: A total of 27 195 singleton pregnant women were included, with a preterm birth rate of 5.08% (1 381/27 195). The preterm birth rates in the low-weight group, normal-weight group and overweight group were 4.29% (138/3 219), 4.63% (852/18 390) and 7.00% (391/5 586) respectively (P<0.001). After adjusting for relevant factors, the Cox proportional hazards model showed that the risk of preterm birth in the overweight group was 1.457 times higher than that in the normal-weight group (95%CI: 1.292-1.643). Preeclampsia-eclampsia (HR=2.701, 95%CI: 1.318-5.537) was the associated factor for preterm birth in the low-weight group. Advanced maternal age (HR=1.232, 95%CI: 1.054-1.441), history of preterm birth (HR=4.647, 95%CI: 3.314-6.515), vaginal bleeding in early pregnancy (HR=1.613, 95%CI: 1.380-1.884), and preeclampsia-eclampsia (HR=3.553, 95%CI: 2.866-4.404) were associated factors for preterm birth in the normal-weight group. Advanced maternal age (HR=1.473, 95%CI: 1.193-1.818), history of preterm birth (HR=3.209, 95%CI: 1.960-5.253), vaginal bleeding in early pregnancy (HR=1.636, 95%CI: 1.301-2.058), preeclampsia-eclampsia (HR=2.873, 95%CI:2.265-3.643), and pre-gestational diabetes mellitus (HR=1.867, 95%CI: 1.283-2.717) were associated factors for preterm birth in the overweight group. Conclusion: Pre-pregnancy overweight is an associated factor for preterm birth, and there are significant differences in the associated factors of preterm birth among pregnant women with different BMI before pregnancy.

Uterine torsion complicated by severe placental abruption in the second trimester: a case report and literature review

BackgroundUterine torsion is a rare obstetric event that can occur during pregnancy and is difficult to diagnose. Its occurrence may lead to serious adverse pregnancy outcomes.Case introductionThe patient was a 33-year-old woman at 30+ 5 weeks’ gestation with a singleton pregnancy. The pregnancy course, including fetal growth, and prenatal examinations were regular. Except for a small amount of vaginal bleeding in early pregnancy and treatment with progesterone, there were no prenatal abnormalities, and the patient denied any trauma or sexual history. The patient was admitted to the emergency department with persistent severe pain in the lower abdomen and slight vaginal bleeding during night sleep. Abdominal pain started two hours prior to admission and was accompanied by nausea, vomiting, and dizziness. Examination revealed positive abdominal tenderness, high uterine tone, and no significant intermittent period of uterine contractions, and measurement of the fetal heart rate by means of the nonstress test revealed a rate of 60 beats per minute. Therefore, placental abruption was highly suspected. Subsequently, an emergency cesarean section was performed under general anesthesia. The newborn boy, with Apgar scores of 0–3-4 after birth and weighing 1880 g, was transferred to the neonatal intensive care unit (NICU) and died two days later due to ineffective rescue. After the uterine incision was sutured, the examination revealed that the uterine incision was located on the posterior wall of the uterus, and the uterus was twisted 180° to the right. The diagnosis after cesarean section was 180° uterine torsion to the right, severe placental abruption, and severe neonatal asphyxia. On the fifth day after surgery, the patient recovered and was discharged from the hospital.ConclusionsPosterior uterine incision cesarean section may be performed in unexpected circumstances and is also feasible as a safe option for resetting if torsion is not complete. Abdominal pain during pregnancy is less likely to be diagnosed as uterine torsion, which often leads to premature birth, fetal asphyxia, placental abruption, and even perinatal death. Therefore, for abdominal pain during pregnancy, obstetricians should consider the possibility of uterine torsion.

A Curious Case of Misapprehension – Dermoid Cyst Masquerading as a Ruptured Ectopic Pregnancy

We discuss the case of a 26-year-old woman who presented with pelvic pain and recent onset vaginal bleeding in early pregnancy. Transvaginal USS identified significant free fluid in the pelvis associated with a right adnexal mass and an empty uterus. A ruptured ectopic pregnancy was suspected, and the patient was taken to theatre for an emergency laparoscopy. Paradoxically, the procedure found no signs of intra-abdominal blood loss. Instead, a large, unruptured 20cm ovarian cyst filled the right adnexa and Pouch Of Douglas (POD), extending posteriorly towards the pelvic brim. It was a right Ovarian, Dermoid cyst. Surprisingly, the dilemma is not unique. We identified similar reports in the literature where unsuspected ovarian pathology is discovered at the time of early pregnancy surveillance, often masquerading as an acute complication of early pregnancy. In this report, the patient went on to have a spontaneous miscarriage, and the cyst was later removed by mini- laparotomy. We present this case as an opportunity to highlight the epidemiology of adnexal pathology presenting for the first time in early pregnancy and to help broaden clinical suspicion when considering potential diagnoses at the time of presentation.

Sonographic Findings in Patients with First Trimester Vaginal Bleeding in Aminu Kano Teaching Hospital

Background: Vaginal bleeding in early pregnancy is a common presentation in acute gyneacological settings. Ultrasonography is a popular and faster option for evaluating patients with these conditions. This is because it is a readily available, safe, and non-invasive imaging method for evaluating pregnancies, especially in the first trimester.&#x0D; Objective: To assess thesonographic findings in pregnant patients with first-trimester vaginal bleeding.&#x0D; Method: This was a cross-sectional descriptive study from patient’s record that was presented to the radiology department for a pelvic ultrasound on account of vaginal bleeding in their first trimester pregnancies for the year 2020. A prepared data collection sheet was used to document the sonographic findings for further analysis. Data were analyzed using SPSS version 16 and the results were presented in tables.&#x0D; Results: A total of 120 pregnant patients were recruited, with their ages ranging from 17- 47 years. The mean age was 29.59± 6.68 years. Threatened abortion was the common finding (32.5%), followed by complete abortion (30.8%), incomplete abortion (24.2%), missed abortion (5%), and ectopic pregnancy (3.3%). Anembyonic pregnancy had (2%) while inevitable abortion and molar gestation had (1.7%) each.&#x0D; Conclusion: Ultrasonography has proven to be a reliable diagnostic tool for patients with the first trimester bleeding Threatened and incomplete abortion were the common sonographic findings. Patients presenting with this clinical indication stand a chance to enjoy the timely results from ultrasound which will facilitate physicians' decision on the next ideal management for better outcomes.

P6 - An Audit of the Early Pregnancy Assessment Service: A retrospective cohort Study

The Early pregnancy Assessment Service (EPAS) was implemented in 2008 at the Liverpool Hospital, NSW. EPAS opens daily assessing and providing care for women presenting with pain and/or vaginal bleeding in early pregnancy. Women with hyperemesis, medical issues such as diabetes, blood pressure, etc or requiring termination of pregnancy are not seen in this service. 1. Length of time women spend in the EPAS aid in the management of staffing and service operations 2. Provide consistent management for outcomes of the current pregnancy. 3. The optimal management for a miscarriage will reflect the woman’s preferred choice, mental health, gestation age, and best practice 4. All women will have a follow up plan after presenting to the EPAS. 1. Women seen in EPAS over a 1 year period (1/1/2018-31/12/2018) 2. Data was extracted from the electronic medical record and paper records of the clinic. 3. Data collected included demographic, background medical and pregnancy histories, gestational age, vaginal bleeding present at initial visit, outcome of current pregnancy, management undertaken, days spent in EPAS, representations to the Emergency Dept. 4. Data was analyzed using SPSSv 26. A total of 966 women were assessed; majority at 9 (7-10) weeks; were 32.2 (28.9-37.9) years of age with 40.7 of women born overseas, and 25.7% from culturally and linguistically diverse (CALD) population. Women presenting for one or more miscarriage accounted for 39% of EPAS presentation, of those women; 18.7% had previous cesarean section; 18.3% had pre-existing co-morbidity; Women presented mostly at 10(7-12) weeks with vaginal bleeding. Over all EPAS presentation; 63% were miscarriage, 30% were found to have a viable pregnancy, 4.3% had an ectopic diagnosed, 0.9% had a molar pregnancy diagnosed. 331 pregnant women has managed by conservative treatment (38.9%), 130 women by medical management (15.3%), and 176 women managed by surgical method (20.7%). 86% of either conservative/medical management (461) being successful, 11.8% of either method failed. The study examined the Early Pregnancy Assessment Service (EPAS) clinic in 2018. Total 966 patients have visited through EPAS. Treatment via EPAS is effective but requires significant time for assessment and follow up visits depending on the gestation presented and management option chosen. Women would find this information helpful when making an informed decision for their preferred care pathway. This would result in higher patient satisfaction. Women with recurrent miscarriage may need improved referral for follow-up and assessment.

Assessment and management of vaginal bleeding in early pregnancy

As vaginal bleeding is a common reason for patients to present for care in the first trimester, this article emphasizes the vital role of nurse practitioners and midwives in caring for them and reviews diagnostic tools and treatment options available to appropriately counsel these patients.

The significance of clinical symptoms of subchorionic hematomas, “bleeding first”, to stratify the high-risk subgroup of very early preterm delivery

ObjectiveTo investigate the factors that stratify high-risk cases among subchorionic hematomas (SCHs) patients with persistent vaginal bleeding in early pregnancy. Materials and methodsA total of 56 patients who required hospitalization for SCH with vaginal bleeding in early pregnancy were classified into two groups: 1) no hematoma by ultrasonography when vaginal bleeding occurred, and then hematoma was observed by ultrasonography “bleeding to hematoma (BH group, n = 15)” and 2) no vaginal bleeding when hematoma was observed by routine ultrasonography, and then vaginal bleeding occurred later “hematoma to bleeding (HB group, n = 41)”. Retrospective cohort study was performed and maternal and neonatal outcomes were evaluated. ResultsThe duration of SCHs and/or vaginal bleeding was significantly longer in the BH group than in the HB group (mean: 60.8 days [BH group] vs. 33.3 days [HB group], p = 0.015). BH group patients delivered earlier than HB group patients significantly (mean: 27.3 weeks [BH group] vs. 35.6 weeks [HB group], p = 0.0028). The frequency of chronic abruption and oligohydramnios sequence (CAOS) was significantly higher in the BH group than in the HB group (3/15; 20.0% [BH group] vs. 0/41; 0.0% [HB group], p = 0.016). The frequency of sever fetal distress (Apgar score <4 points) was significantly higher in the BH group than in the HB group (4/15; 26.7% [BH group] vs. 0/41; 0.0% [HB group], p = 0.0037). The levels of factor XIII were relatively lower in the BH group than in the HB group (mean: 54.8% (n = 4) [BH group] vs. 76.1% (n = 7) [HB group], p = 0.077). ConclusionThe order of the symptoms, bleeding first, is an important feature that reflects the subsequent prolonged duration of SCHs/vaginal bleeding, resulting in very early preterm delivery. Continuous hemorrhage consumes coagulation factor XIII, which further worsen the hemostasis.

Progesterone for the prevention of threatened miscarriage

Miscarriage, defined as the loss of a pregnancy before 24 weeks of gestation, is the most common complication of early pregnancy, affecting approximately 15% of clinically recognized pregnancies. The steroid hormone progesterone is essential for the maintenance of pregnancy, and progesterone deficiency is associated with miscarriage. Two important clinical risk factors for miscarriage are a history of previous miscarriages and vaginal bleeding in early pregnancy. Progesterone supplementation has therefore been attempted to prevent miscarriages in asymptomatic women with a history of miscarriages and in women who have started to bleed in early pregnancy. The latest evidence from high quality clinical trial research has shown that vaginal micronized progesterone treatment of women with the dual risk factors of early pregnancy bleeding and a history of one or more previous miscarriages increases the likelihood of a successful live birth (relative rate 1.08, 95% CI 1.02 to 1.15, high-certainty evidence). This treatment has also been shown to be cost-effective, leading to the National Institute for Health and Care Excellence committee for the guideline ‘Ectopic pregnancy and miscarriage: diagnosis and initial management (NG126)’ updating their guidance to recommend the use of vaginal micronized progesterone to treat women with the dual risk factors of a history of one or more previous miscarriages and early pregnancy bleeding. This change in practice has the potential to prevent up to 8,450 miscarriages a year in the UK.

A cost-minimisation analysis of performing point-of-care ultrasonography on patients with vaginal bleeding in early pregnancy in general practice: a decision analytical model

BackgroundSpotting and light vaginal bleeding are common and usually harmless symptoms in early pregnancy. Still, vaginal bleeding may be the first sign of an abortion and often causes distress to pregnant women and leads to an expectation of an ultrasonography examination of the uterus. As point-of-care ultrasonography (POCUS) is increasingly being integrated into general practice, these patients may be clinically evaluated and managed by general practitioners (GPs). This can potentially reduce referrals of patients from the primary to the secondary healthcare sector resulting in societal cost-savings.The primary purpose of this study was to investigate whether the accessibility of POCUS in general practice for patients with vaginal bleeding in early pregnancy is cost-saving compared to usual practice where GPs do not have access to POCUS. A secondary purpose of this study was to estimate a remuneration for GPs performing POCUS on these patients in general practice.MethodsA cost-minimisation analysis was based on a decision tree model reflecting the two alternatives: general practice with and without GPs having access to POCUS. The robustness of the model results was investigated using probabilistic sensitivity analysis and the following deterministic sensitivity analyses: one-way analyses for the model input parameters and a scenario analysis with a change from a societal to a healthcare sector perspective.An expected remuneration reflecting the add-on cost of Danish GPs performing POCUS was estimated based on the related costs: cost of an ultrasonography scanner, GP’s time consumption, ultrasonography training, and utensils per scanning.ResultsThe difference in average cost between the two alternatives from a societal perspective was estimated to be €110, in favour of general practice with GPs using POCUS. The deterministic sensitivity analyses demonstrated robustness of the results to plausible changes in the input parameters.The expected remuneration for performing POCUS in this specific setting was estimated to be €32 per examination.ConclusionHaving GPs perform POCUS on patients with vaginal bleeding in early pregnancy is cost-saving compared to usual practice. The results should be taken with caution as this study was based on early modelling with uncertainties associated with the input parameters in the model.

Pregnancy outcomes in women with vaginal bleeding in early pregnancy

Background: Vaginal bleeding in early pregnancy is a common complaint of pregnant women and its incidence has been reported as 16% to 25%. About half of the patients with vaginal bleeding will abort and remaining poor pregnancy outcomes such as preterm delivery, preterm premature rupture of membranes (PPROM), and intrauterine fetal growth restriction can occur. Aims and Objectives: To study the association of vaginal bleeding in early pregnancy as a useful indicator of pregnancies at risk and to determine the associated perinatal outcome and pregnancy complications. Materials and Methods: A 1-year retrospective study was conducted on a total of 360 patients, comprising 120 women with early pregnancy bleeding and 240 women without bleeding. Pregnancy complications and perinatal outcomes were compared between these two groups of pregnant patients. Results: Out of 120 cases with early pregnancy bleeding, 52.88% aborted, and 47.12% continued their pregnancy beyond 20 weeks. Among those cases that reached beyond 20-week gestation, 48.98% of women delivered prematurely (<37 weeks) and 51.02% delivered at term. Women with vaginal bleeding had onset of preterm labor in 32.65%, antepartum hemorrhage in 18.37%, placenta previa in 8.16%, and low birth weight babies in 53.06% of cases. In contrast, cases without vaginal bleeding in early pregnancy had preterm labor in 2.92%, antepartum hemorrhage in 1.67%, placenta previa in 0.42%, and low birth weight babies in 10.83% of cases. Conclusion: Bleeding in early pregnancy increases the risk of pregnancy complications such as preterm delivery, abortion, antepartum hemorrhage, placenta previa, PPROM, fetal growth restriction, and low birth weight in neonates. Therefore, it is a useful indicator of pregnancy complications and adverse outcomes.

Efficacy of vaginal administration of Crinone versus Utrogestan combined with oral dydrogesterone tablets for luteal support in PGT freeze-thaw embryo transfer cycles

To compare the efficacy of two vaginal progesterone formulations, Crinone gel or Utrogestan capsules, combined with dydrogesterone tablets, for luteal phase support in pre-implantation genetic testing (PGT) freeze-thaw embryo transfer (FET) cycles. We analyzed 209 FET cycles in patients undergoing PGT-blastocyst transfer in our center between June, 2017 and June, 2020. The patients received vaginal administration of either Crinone gel (n=135) or Utrogestan capsules (n=74) combined with oral dydrogesterone tablets for luteal supplementation, and the clinical pregnancy rate (CPR) and miscarriage rate (MR) were compared between the two groups. The Crinone gel and Utrogestan capsule groups were comparable for age, duration of infertility, AMH, AFC, BMI, basal FSH, LH, and E2 (P > 0.05). The gonadotrophin dose, duration of stimulation, levels of LH, E2, P and endometrial thickness on hCG day, and the numbers of oocytes retrieved, MII oocytes, 2PN and blastocysts did not differ significantly between two groups (P > 0.05). In FET cycles, no significant differences were observed between the two groups in the duration of endometrial preparation, P and endometrial thickness on endometrial transformation day, biochemical pregnancy rate (69.63% vs 78.38%), CPR (62.96% vs 72.97%), MR (12.94% vs 11.11%), vaginal bleeding rate in early pregnancy (20% vs 27.78%), or MR in patients with vaginal bleeding in early pregnancy (35.29% vs 20%) (P > 0.05). Crinone gel and Utrogestan capsules combined with oral dydrogesterone have similar clinical efficacy for luteal support in PGT FET cycles.

LO01: What presenting features predict obstetrical outcomes in women who present to the emergency department with early pregnancy bleeding?

Introduction: Vaginal bleeding in early pregnancy is a common emergency department (ED) presentation, with many of these episodes resulting in poor obstetrical outcome. These outcomes have been extensively studied, but there have been few evaluations of what variables are associated predictors. This study aimed to identify predictors of less than optimal obstetrical outcomes for women who present to the ED with early pregnancy bleeding. Methods: A regional centre health records review included pregnant females who presented to the ED with vaginal bleeding at &lt;20 weeks gestation. This study investigated differences in presenting features between groups with subsequent optimal outcomes (OO; defined as a full-term live birth &gt;37 weeks) and less than optimal outcomes (LOO; defined as a miscarriage, stillbirth or pre-term live birth). Predictor variables included: maternal age, gestational age at presentation, number of return ED visits, socioeconomic status (SES), gravida-para-abortus status, Rh status, Hgb level and presence of cramping. Rates and results of point of care ultrasound (PoCUS) and ultrasound (US) by radiology were also considered. Results: Records for 422 patients from Jan 2017 to Nov 2018 were screened and 180 patients were included. Overall, 58.3% of study participants had a LOO. The only strong predictor of outcome was seeing an Intra-Uterine Pregnancy (IUP) with Fetal Heart Beat (FHB) on US; OO rate 74.3% (95% CI 59.8-88.7; p &lt; 0.01). Cramping (with bleeding) trended towards a higher rate of LOO (62.7%, 95% CI 54.2-71.1; p = 0.07). SES was not a reliable predictor of LOO, with similar clinical outcome rates above and below the poverty line (57.5% [95% CI 46.7-68.3] vs 59% [95% CI 49.3-68.6] LOO). For anemic patients, the non-live birth rate was 100%, but the number with this variable was small (n = 5). Return visits (58.3%, 95% CI 42.2-74.4), previous abortion (58.8%, 95% CI 49.7-67.8), no living children (60.2%, 95% CI 50.7-69.6) and past pregnancy (55.9%, 95% CI 46.6-65.1) were not associated with higher rates of LOO. Conclusion: Identification of a live IUP, anemia, and cramping have potential as predictors of obstetrical outcome in early pregnancy bleeding. This information may provide better guidance for clinical practice and investigations in the emergency department and the predictive value of these variables support more appropriate counseling to this patient population.

Need of Sonography in Vaginal Bleeding in Early Pregnancy; As a Primary Investigation

Need of Sonography in Vaginal Bleeding in Early Pregnancy; As a Primary Investigation

A Randomized Trial of Progesterone in Women With Bleeding in Early Pregnancy

(N Engl J Med. 2019;380(19):1815–1824) This study aimed to determine whether the controversial use of progesterone therapy in women with early bleeding in pregnancy could result in a higher incidence of live births than use of a placebo. It was a multicenter, randomized, double-blind, placebo-controlled trial to evaluate progesterone, as compared with placebo, in women with vaginal bleeding in early pregnancy. Women received vaginal suppositories of progesterone, or a placebo, from presentation of bleeding to 16 weeks to determine if progesterone therapy helps improve pregnancy outcomes for women with vaginal bleeding in early pregnancy.

Vaginal bleeding in early pregnancy and risk of occult cancer.

Vaginal bleeding in early pregnancy is not associated with a higher cancer risk compared with pregnancies in women from the general population of similar age.

A Randomized Trial of Progesterone in Women with Bleeding in Early Pregnancy

BackgroundBleeding in early pregnancy is strongly associated with pregnancy loss. Progesterone is essential for the maintenance of pregnancy. Several small trials have suggested that progesterone therapy may improve pregnancy outcomes in women who have bleeding in early pregnancy.MethodsWe conducted a multicenter, randomized, double-blind, placebo-controlled trial to evaluate progesterone, as compared with placebo, in women with vaginal bleeding in early pregnancy. Women were randomly assigned to receive vaginal suppositories containing either 400 mg of progesterone or matching placebo twice daily, from the time at which they presented with bleeding through 16 weeks of gestation. The primary outcome was the birth of a live-born baby after at least 34 weeks of gestation. The primary analysis was performed in all participants for whom data on the primary outcome were available. A sensitivity analysis of the primary outcome that included all the participants was performed with the use of multiple imputation to account for missing data.ResultsA total of 4153 women, recruited at 48 hospitals in the United Kingdom, were randomly assigned to receive progesterone (2079 women) or placebo (2074 women). The percentage of women with available data for the primary outcome was 97% (4038 of 4153 women). The incidence of live births after at least 34 weeks of gestation was 75% (1513 of 2025 women) in the progesterone group and 72% (1459 of 2013 women) in the placebo group (relative rate, 1.03; 95% confidence interval [CI], 1.00 to 1.07; P=0.08). The sensitivity analysis, in which missing primary outcome data were imputed, resulted in a similar finding (relative rate, 1.03; 95% CI, 1.00 to 1.07; P=0.08). The incidence of adverse events did not differ significantly between the groups.ConclusionsAmong women with bleeding in early pregnancy, progesterone therapy administered during the first trimester did not result in a significantly higher incidence of live births than placebo. (Funded by the United Kingdom National Institute for Health Research Health Technology Assessment program; PRISM Current Controlled Trials number, ISRCTN14163439.)

Maternal severe stressful life events and risk of abnormal vaginal bleeding among urban Chinese pregnant women

Objective: The objective of this study is to assess whether maternal stressful life events are associated with increased risk of vaginal bleeding in urban China.Methods: We implemented a cross-sectional study to examine the association between maternal severe stressful life events and vaginal bleeding in early pregnancy. Information was collected from an urban area and 956 participants were involved in final analysis. Multivariable logistic model was used to estimate the adjusted odds ratio (OR) and 95% confidence interval (95% CI) controlling for confounders.Results: In total, 219 of the 956 participants were reported vaginal bleeding. Maternal stressful life events would increase the chance of vaginal bleeding with a crude OR of 2.14 (95% CI, 1.53–2.99). After adjustment for potential variables, the association remains significant (adjusted OR, 2.22; 95% CI, 1.56–3.16), and stratification analysis shows parity is an influence factor. The frequency of maternal stress and vaginal bleeding exist a dose–response relationship.Conclusion: Maternal stressful life events are associated with the risk of vaginal bleeding in urban China. The parity status influences their association.

Anxiety associated with diagnostic uncertainty in early pregnancy

To determine anxiety levels of women presenting to an early pregnancy assessment unit (EPAU) with abdominal pain and/or vaginal bleeding and to assess how these levels change over time and according to ultrasonographic diagnosis. We undertook a prospective cohort study in an EPAU in a large UK teaching hospital. Women with abdominal pain and/or vaginal bleeding in early pregnancy (< 12 weeks' gestation) presenting for the first time were eligible for inclusion in the study. State anxiety levels were assessed using the standardized short form of Spielberger's state-trait anxiety inventory (STAI) on three occasions (before, immediately after and 48-72 hours after an ultrasound scan). Scores were correlated with ultrasonographic diagnosis. The diagnosis was either certain or uncertain. Certain diagnoses were either positive, i.e. a viable intrauterine pregnancy (IUP), or negative, i.e. a non-viable IUP or ectopic pregnancy. Uncertain diagnoses included pregnancy of unknown location and pregnancy of uncertain viability. Statistical analysis involved mixed ANOVAs and the post-hoc Tukey-Kramer test. A total of 160 women were included in the study. Anxiety levels decreased over time for women with a certain diagnosis (n = 128), even when negative (n = 64), and increased over time for women with an uncertain diagnosis (n = 32). Before the ultrasound examination, anxiety levels were high (STAI value, 21.96 ± 1.11) and there was no significant difference between the five groups. Immediately after the ultrasound examination, anxiety levels were lower in the viable IUP group (n = 64; 7.75 ± 1.13) than in any other group. The difference between the five groups was significant (P < 0.005). After 48-72 hours, women with a certain diagnosis had significantly lower anxiety levels than had those with an uncertain diagnosis (10.77 ± 4.30 vs 22.94 ± 1.65; P < 0.005). The experience of abdominal pain and/or vaginal bleeding in early pregnancy is highly anxiogenic. Following an ultrasound examination, the certainty of the diagnosis affects anxiety levels more than does the positive or negative connotations associated with the diagnosis per se. Healthcare providers should be aware of this when communicating uncertain diagnoses. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.