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Vaginal bleeding < 20 ges ws is the commonest

complication in pregnancy, occurring in 1/5 of cases.

17% of cases are expected to present complications

later in pregnancy (Johns et al, 2003).

Management is mostly empirical.

Bed rest is routinely recommended.

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There was a significant association between TM

and:

(Elnashar et al, 1998)

1. Abruptio placentae (bleeding in 2nd trimester)

2. PTL

3. SFGA

4. Increased CS rate (bleeding in 2nd trimester)

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•One in five pregnancies is complicated by TM

•Adverse prognostic factors:

1.

advanced maternal age,

history of RPL,

2.

large empty gest sac,

discrepancy bet gest age &CRL,

fetal bradycardia or absence of FH,

3.

progesterone < 45 nmol/l or

low hCG or inhibin A

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•Favorable prognosis

FH activity and

lack of adverse prognostic factors

•Although bed rest and progesterone supplements

are often advised, little evidence supports their

effectiveness

•Give anti-Rh D Ig to non-sensitized women with

symptoms near, at, or after 12 gest weeks

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1. Older women (>34 ys)

are at increased risk of miscarriage.

2. Previous miscarriages is associated with

increased risk in future pregnancies, especially in

older women (Falco et al, 1996)

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To dd between genital and extragenital causes.

uterus,

cervix,

vagina, or

extragenital.

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1.DD between intrauterine pregnancy

(viable or non-viable), molar pregnancy,

inevitable abortion.

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U/S findings of TM:

1. Intact pregnancy (50 % )

2. Missed abortion (25 %)

3. Blighted ovum (20 %)

4. Incomplete abortion (3 %)

5. Ectopic pregnancy (2 %)

6. Hydatiform mole (< 1 %)

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loop

Non cystic mass

D pouch

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2. Prediction of outcome. a. An empty ges sac 15 mm at 7 w & 21 mm at 8 W has diagnostic accuracy of

90.8% (Falco et al, 2003).

b. A mean sac diameter 17 mm without an embryo or 13 mm without a yolk sac can predict non-

viable gestation with a specificity and a positive predictive value of 100%

(Tongsong et al, 1996).

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c. Fetal heart activity should be visible with

TVS once the fetal pole is 5 mm long (Falco et al, 2003). a loss rate of 5% if bleeding occurs after FH starts (Tanninrandorn et al, 2003)

Identification of FH carries a 97% likelihood for the pregnancy continuing beyond 20 ws (Everett et al,1996)

This favorable effect has not been universally repeated, as miscarriage rates of 20-30% have been reported (La Marca et al, 1998)

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d. Fetal bradycardia Discrepancy bet ges sac & CRL Discrepancy bet ges & US age>1w

(Makridimas et al, 2003) increases the rate of abortion from 6% when none are present to 84% when all 3 are present (Falco et al, 1996)

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e. Subchorionic haematoma.

•large haematoma:

3fold increase of risk of miscarriage (19% v 71%) (Bennet et al, 1996)

•The presence or the vol of haematoma:

did not affect miscarriage rate (10% v 11%) (Falco et al, 2003)

•Relative vol (vol of haematoma/vol of ges sac)

>40%:

increase risk of miscarriage (Elnashar, 1999)

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Normal subplacental

vascular bed

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•The presence of haematoma in the first trimester:

increases the risk of severe obstetric complications,

irrespective of the presence of symptoms of TM (Nagy et al, 2003)

•However, the presence of a haematoma did not

influence the risk for subsequent complications in a

smaller study of symptomatic women (Johns et al, 2003)

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1.HCG:

a. In first trimester a free hCG cut-off value of 20

ng/ml could dd bet normal (control and

threatened continuing)& abnormal (non-

continuing TM and tubal) pregnancies, with

88.3% sensitivity and

82.6% positive predictive value (Alsebaie et al, 1996)

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b. The bioactive to immunoreactive ratio of serum

hCG was higher in symptomatic women who

continued with pregnancy than in women who

eventually miscarried (Tongsong et al, 1995)

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2. Progesterone concentrations

•5.1 ng/ml: The lowest concentration associated with

a viable first trimester pregnancy (Tannirandorn et al, 2003)

•25 ng/ml: 97% likelihood for viable IU pregnancy

more sensitive than two serial hCG measurements (Everett et al, 1996)

•<14 ng/ml (45 nmol/l ) dd bet abnormal and normal

(ongoing) pregnancies, with a sensitivity of 87.6% &

specificity of 87.5% (Alsebaei et al, 1995)

3. CA125:

•Constant or increasing over 5-7 days: Miscarriage

•Constantly low or steeply declining: Pregnancy

continuation (Schmidt et al, 2001)

•>43.1 IU/ml: greater risk of miscarriage (Fiegler et al, 2003)

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4. Pregnancy associated placental protein A

(PAPP-A) is lower in symptomatic women with FH

than in normal controls,

its predictive value for miscarriage was only 18.7% (Ruge et al, 1990)

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•Doctors:

96% prescribe bed rest

1/8: it is mandatory

1/3: it affects outcome (Everett et al,1987)

• One small RCT

one observational study

one retrospective study, yielding conflicting results.

•An observational cohort study:

Bed rest: Miscarriage rate of 9.9%

No bed rest: Miscarriage rate 23.3% (P = 0.03) (Ben-Haroush et al, 2003).

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Cochrane library (2005):

•There is insufficient evidence of high quality that

supports bed rest in order to prevent miscarriage in

women with confirmed fetal viability and vaginal

bleeding in first half of pregnancy

•There was no statistically significant difference in

the risk of miscarriage in the bed rest group Vs the

no bed rest group

•Neither bed rest in hospital nor bed rest at home

showed a significant difference in the prevention of

miscarriage.

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for a couple of days may help women feel safer (La Marca et al, 1998)

thus providing emotional relief.

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(RCT, Harison, 1993)

•Significant differences bet hCG & bed rest groups but

No sig dif bet hCG & placebo groups or bet placebo &

bed rest groups.

• With hCG:

risk of OHSS, and

TM may be the result of various conditions, irrelevant

to luteal function, prevented further testing and

application of hCG

hCG Placebo Bed rest

Abortion

(%)

30 48 75

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•Prescribed in: 13-40% (Johns et al, 2003)

•Action: Support corpus luteum,

Relax the uterus

•RCT: Progestagen do not improve outcome (Pedersen & Mantoni, 1990; al-Sebaei et al, 1996).

•Local progestogen: decreases uterine

cramping more rapidly than bed rest (Dickey et al, 1992)

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RCT:

Buphenine hydrochloride was better than placebo (Nagy et al, 2003) Cochrane library (2005):

There is insufficient evidence to support the use of

uterine muscle relaxant drugs for women with TM

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RCOG & ACOG Guidelines:

•Rh D alloimmunisation attributable to first trimester

TM is rare

•Anti-D Img:

1. Non-sensitized Rh D negative with TM after 12 w

2. Heavy or repeated bleeding or

abdominal pain, particularly as gestation

approaches 12 w.

3. Not necessary in TM with a viable fetus &

cessation of bleeding <12 w

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•TM occurs often and is a serious emotional

burden for women.

•Sonographic evaluation can dd between IU

and extrauterine pregnancy and offer some

prognostic clues.

•Demonstration of FH is associated with a

successful pregnancy rate of 85-97%,

•An empty large ges sac or a discrepancy bet

menstrual & sonographic age of >week

indicates a poor prognosis.

•Advanced maternal age and increasing

number of previous miscarriages deteriorates

prognosis.

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•Serum hCG, progesterone, & CA125

concentrations may be helpful as

predictors; however, these tests may not

be useful in primary care settings.

•Although many women with TM are

given progestogens and are prescribed

bed rest, little evidence supports these

policies.

•Short term abstinence from usual

activity may be feasible for women to

relieve their stress.

•Rhesus sensitization is rare after first

trimester TM; however, anti-D Ig should

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