Diagnosing miscarriage (original) (raw)
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Defining safe criteria to diagnose miscarriage: prospective observational multicentre study
ObjeCtives To validate recent guidance changes by establishing the performance of cut-off values for embryo crown- rump length and mean gestational sac diameter to diagnose miscarriage with high levels of certainty. Secondary aims were to examine the influence of gestational age on interpretation of mean gestational sac diameter and crown-rump length values, determine the optimal intervals between scans and findings on repeat scans that definitively diagnose pregnancy failure.) Design Prospective multicentre observational trial. setting Seven hospital based early pregnancy assessment units in the United Kingdom. PartiCiPants 2845 women with intrauterine pregnancies of unknown viability included if transvaginal ultrasonography showed an intrauterine pregnancy of uncertain viability. In three hospitals this was initially defined as an empty gestational sac <20 mm mean diameter with or without a visible yolk sac but no embryo, or an embryo with crown-rump length <6 mm with no heartbeat. Following amended guidance in December 2011 this definition changed to a gestational sac size <25 mm or embryo crown-rump length <7 mm. At one unit the definition was extended throughout to include a mean gestational sac diameter <30 mm or embryo crown-rump length <8 mm. Main OutCOMe Measures Mean gestational sac diameter, crown-rump length, and presence or absence of embryo heart activity at initial and repeat transvaginal ultrasonography around 7-14 days later. The final outcome was pregnancy viability at 11-14 weeks’ gestation. results The following indicated a miscarriage at initial scan: mean gestational sac diameter ≥25 mm with an empty sac (364/364 specificity: 100%, 95% confidence interval 99.0% to 100%), embryo with crown-rump length ≥7 mm without visible embryo heart activity (110/110 specificity: 100%, 96.7% to 100%), mean gestational sac diameter ≥18 mm for gestational sacs without an embryo presenting after 70 days’ gestation (907/907 specificity: 100%, 99.6% to 100%), embryo with crown-rump length ≥3 mm without visible heart activity presenting after 70 days’ gestation (87/87 specificity: 100%, 95.8% to 100%). The following were indicative of miscarriage at a repeat scan: initial scan and repeat scan after seven days or more showing an embryo without visible heart activity (103/103 specificity: 100%, 96.5% to 100%), pregnancies without an embryo and mean gestational sac diameter <12 mm where the mean diameter has not doubled after 14 days or more (478/478 specificity: 100%, 99.2% to 100%), pregnancies without an embryo and mean gestational sac diameter ≥12 mm showing no embryo heartbeat after seven days or more (150/150 specificity: 100%, 97.6% to 100%). COnClusiOns Recently changed cut-off values of gestational sac and embryo size defining miscarriage are appropriate and not too conservative but do not take into account gestational age. Guidance on timing between scans and expected findings on repeat scans are still too liberal. Protocols for miscarriage diagnosis should be reviewed to account for this evidence to avoid misdiagnosis and the risk of terminating viable pregnancies.
Journal of Ultrasound in Medicine, 2020
Objectives-(1) To study the predictors of pregnancy continuation up to 28 weeks in first-trimester threatened miscarriage after a single clinical and ultrasound (US) evaluation. (2) To assess the role of both clinical and US predictors in counseling and decreasing repeated emergency follow-up scans. Methods-A prospective observational study that included a cohort of 241 patients with threatened miscarriage (≥6-12 weeks) was conducted. They had a single clinical and US evaluation, and then they were contacted by weekly phone calls until completing 28 weeks' gestation or reporting miscarriage. Independently, all patients were followed by the recommended routine US scanning with or without emergency visits. Results-Two hundred thirty-three patients completed the study, of whom 193 patients continued up to 28 weeks' gestation, and 40 miscarried (17.1%). Only spotting/mild bleeding episodes and progesterone treatment were the clinical predictors of fetal viability. The embryonic/fetal heart rate (E/FHR) was the best single US predictor, with a specificity and positive predictive value of 95.3% and 97.2%, respectively. Combining 3 US parameters, at their best cutoff points (E/FHR >113 beats per minute, crown-rump length >13.9 mm, and gestational sac diameter >27.3 mm), had a specificity and positive predictive value of 98% and 99% (first-trimester US triad of fetal viability). Conclusions-[1] In first-trimester threatened miscarriage, clinical parameters that could predict fetal viability included shortspotting/ mild bleeding and progesterone treatment. [2] After a single US scan, the presence of at least an E/FHR of greater than 113 bpm or the suggested first-trimester US triad appeared as a simple, measurable, and effective predictor of pregnancy continuation up to 28 weeks. [3] These US predictors are not to replace the recommended scheduled scanning during pregnancy. [4] This can improve patients' counseling and decrease the need for repeated emergency follow-up scans. Otherwise, there is an indication for repeating US scans at a 1-week to 10-day interval.
Threatened miscarriage: evaluation and management
BMJ, 2004
Threatened miscarriage-vaginal bleeding before 20 gestational weeks-is the commonest complication in pregnancy, occurring in about a fifth of cases. w1 Miscarriage is 2.6 times as likely, 1 and 17% of cases are expected to present complications later in pregnancy. 2 Although general practitioners and gynaecologists often see this condition, management of threatened miscarriage is mostly empirical. Bed rest is routinely recommended, and about a third of women presenting with threatened miscarriage are prescribed drugs. w2 However, two thirds of the general practitioners recommending this do not believe it affects outcome. In this review, we present available evidence on the initial evaluation and management of threatened miscarriage, focusing mainly on the first trimester of pregnancy and primary healthcare settings.
How should success be defined when attempting medical resolution of first-trimester missed abortion?
European Journal of Obstetrics & Gynecology and Reproductive Biology, 2005
Objectives: There is currently no consensus on how success should be defined after medical management of first-trimester missed abortion. The aim of this study was to determine the transvaginal ultrasound criterion associated with highest success rate and, at the same time, lowest long-term complications. Design: Prospective observational study of consecutively enrolled patients. Setting: A tertiary care university hospital in northern Portugal. Participants : Forty-four women submitted to medical management of first-trimester missed abortion using a regimen of vaginal misoprostol, with histologically confirmed conception products passed vaginally. A transvaginal ultrasound scan was performed by an experienced sonographer in the morning after treatment, to characterise uterine content. Patients were provided with a chart for daily registration of axillary temperature, vaginal bleeding and lower abdominal pain. Transvaginal ultrasound was repeated 2-3 weeks later, and again after the following menses. Main outcome measures: Success rates of medical management when post-treatment transvaginal ultrasound criteria for subsequent expectant management were: absence of intra-uterine sac, largest anteroposterior diameter of hyperechogenic content, and maximum area of hyperechogenic intra-uterine content in a sagittal view. Self-reported duration of vaginal bleeding and abdominal pain after medical treatment. Results: Success rate was 86% (38/44) when absence of gestational sac on the 12 h transvaginal ultrasound was used as the main criterion for subsequent expectant management and there was no need for further intervention. The success rate using the ultrasound criterion anteroposterior diameter 15 mm was 51% (22/43), and with maximum sagittal plane area under 7.5 cm 2 , 72% (31/43). Mean duration of vaginal haemorrhage was 9 days (minimum 2 days, maximum 14 days) and of lower abdominal pain 6 days (minimum 0 days, maximum 14 days). No patient recorded an axillary temperature exceeding 37 8C. No apparent relationship between the size of ultrasound-estimated intrauterine content and duration of symptoms was observed. Conclusions: Absence of gestational sac on transvaginal ultrasound should be the criterion used to document success after medical management of first-trimester missed abortion, as it is associated with the highest short and long-term success rates, as well as mild and selflimited symptoms in the days following treatment.
Accuracy of prenatal diagnosis in elective termination of pregnancy: 385 cases from 2000 to 2007
ISRN obstetrics and gynecology, 2011
To evaluate the quality of prenatal results in all cases of termination of pregnancy (TOP) due to fetal abnormalities in a tertiary prenatal diagnosis center. Material and Methods. Retrospective analysis of the 385 TOP performed on our department due to fetal abnormalities between January 1, 2000, and December 31, 2007. We compared all data for agreement between the ultrasound, genetic, and postmortem findings, regarding the abnormalities identified in the etiological diagnosis and its prognosis. Results. Chromosome abnormalities were the most common indication for TOP (39%), followed by abnormalities of CNS (20%), monogenic disorders (11%), sequences (9.6%), polimalformative syndromes (5.2%), and isolated congenital heart diseases (4%). Total agreement was 21%. Further abnormalities were identified in 79%. The data collected after TOP changed the etiologic diagnosis in 21% but the prognosis was changed in only one fetus. Discussion. This study corroborates the necessity of a multidisciplinary team in prenatal diagnosis centers. Their work remarkably improves the genetic counseling and represents an important aspect in quality control of the information given to a couple previously to a TOP.
Miscarriage Definitions, Causes and Management: Review of Literature
ARC Journal of Gynecology and Obstetrics, 2017
Biochemical pregnancy loss or miscarriage is the pregnancy loss, which occurs after positive urinary or serum human chorionic gonadotropin (hCG), but before ultrasound or histological detection of pregnancy (<6 weeks) [1]. Clinical pregnancy loss or miscarriage is the pregnancy loss, which occurs after ultrasound detection of intrauterine gestational sac, and confirmed by histological evidence of products of conception after the miscarriage [1]. Clinical miscarriages divided to; early clinical pregnancy losses (<12 weeks), and late clinical pregnancy losses (between 12-21 weeks). The ESHRE (European Society of Human Reproduction, and Embryology) defined RM as ≥3 consecutive pregnancy losses before 22 weeks [2]. 2. EPIDEMIOLOGY OF MISCARRIAGE The use of sensitive, and accurate urinary hCG assays in the diagnosis of pregnancy demonstrated that only one-third of conceptions progress to a live birth. Thirty percent of human conceptions are lost before implantation, and another 30% after implantation but before the missed menses (3 rd or 4 th week), and both termed as preclinical losses [3]. Figure 1 The incidence of early clinical miscarriage is about 10-15%. The incidence of late miscarriage is about 4% [4]. Compared to sporadic miscarriage the incidence of RM is 0.8-1.4% if only clinical pregnancy included, and 2-3% if biochemical pregnancy included [4]. Maternal age, and number of previous miscarriages are two independent risk factors for a further Abstract: The ESHRE defined recurrent miscarriage (RM) as ≥3 consecutive pregnancy losses before 22 weeks` gestation. Five to fifteen percent of RM women have significantly elevated anti-phospholipid antibodies, and 85% of the RM couples had elevated levels of sperm DNA damage. Endometrial stromal cells from women with RM are more receptive (super receptivity) for low-quality embryos. The risk of sporadic and/or RM increased in women with positive thyroperoxidase antibodies (TPO-Ab), and the risk of miscarriage doubled in women with TSH >2.5 mIU/L in the first trimester. A systematic review concluded that the prevalence of all uterine malformations was 15.4% among RM women. Women with body mass index ≥25 kg/m 2 have increased risk of miscarriage compared to women with BMI <25 kg/m 2. IVF with prenatal genetic testing suggested as treatment for RM due to chromosomal abnormalities. The majority of women (65-85%) with uterine malformations as bicornuate or septate uterus have successful pregnancy after metroplasty, and the hysteroscopic metroplasty should be done only for women with septate uteri, after failed previous IVF-ET trials. Empirical progesterone may beneficial for women with ≥3 consecutive miscarriages immediately preceding their current pregnancy. Combination of lower molecular weight heparin, and aspirin is superior to aspirin alone in the treatment of RM due to antiphospholipid syndrome.