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Role of pelvic sonography in first trimester bleeding.

INTRODUCTION: In Obstetrics, first trimester bleeding, is bleeding from the vagina during pregnancy in the first trimester. The first trimester extends through completion of 14 weeks. (1)

First trimester bleeding is a common occurrence and estimated to occur in approximately 25% of all (clinically recognized) pregnancies. (2,3)

Obstetrics is "bloody business." The most common indication for emergency referral in early pregnancy is vaginal bleeding. Today an ultrasound assessment of the pregnancy is a natural part of a first-trimester clinical examination.

In these women who present with bleeding per vaginum, during their first trimester several diagnostic possibilities can be considered. By mere clinical history and examination definitive diagnosis is usually difficult. The causes of bleeding are many and cover a spectrum of conditions ranging from a viable pregnancy to non-viable pregnancy.

Ultrasonographic evaluation is also applied earlier in gestation to provide information to clinicians and patients about the integrity of the pregnancy. Ultrasound (both trans-abdominal and transvaginal sonography) plays an important role in the evaluation of the causes of the first trimester bleeding, prognosticate and predict the status of abnormal pregnancy. Real time sonography is an accurate diagnosis. Ultrasonography is generally considered a safe imaging modality. (4) World Health Organizations technical report series 875 (1998). (5) Supports that ultrasound is harmless.

Randomized controlled study have followed children up to ages 8-9, with no significant differences in vision, hearing, school performance, dyslexia, or speech and neurologic development by exposure to ultrasound. (6) The social phenomena of increasing maternal age predisposing to abortion, general limitation of family size and heightened expectations of normal outcome have produced increased pressure on the obstetrician, thereby giving more importance to ultrasonography.:

Ultrasound in a woman who presents with bleeding in the first trimester helps,

1. In confirming the pregnancy.

2. To confirm the pregnancy location, revealing whether it is a definitive intrauterine or definitive ectopic gestation.

3. More accurate diagnosis of embryonic and fetal viability, even in the first trimester, through the assessment of cardiac activity.

4. Early pregnancies can be dated accurately by sequential sonographic visualization of the gestational sac, yolk sac, embryonic pole, cardiac activity, and amniotic sac.

5. To confirm or rule out suspected hydatidiform mole.

6. To look for the presence of intrauterine contraceptive device (IUCD) and confirmation of pregnancy associated with IUCD.

7. Helps in early detection of anembryonic pregnancy.

8. Evaluation of threatened, incomplete, complete, inevitable or missed abortion.

9. Helps in prompt management of the patients.

10. It can detect many pregnancy complications, such as placental abnormalities.

MATERIALS AND METHODS: Source of data: Study includes all Obstetric cases attending Bhabha Atomic Research Centre and Hospital with history of bleeding per vaginum in first trimester of pregnancy during the study period October 2011 to September 2013. The study was granted ethical approval from the local ethics committees. All women participated voluntarily, having given their informed consent.

Sample Size: 100 cases who presented with history of bleeding in first trimester of pregnancy have been included in the study.

Inclusion Criteria: All patients with clinically suspected first trimester bleeding (<14 completed weeks) of pregnancy.

Exclusion Criteria:

1. All local lesions causing vaginal bleeding.

2. All patients with more than 14 completed weeks of gestation.

METHOD OF COLLECTION OF DATA: It is a hospital based prospective study of patients who present with bleeding per vaginum in the first trimester of pregnancy during the study period.

Clinical details like age, parity, obstetric history, personal history, medical history, past history, menstrual history and details of present pregnancy in terms of period of amenorrhea at the time of first episode of bleeding, amount and duration of bleeding whether associated with pain abdomen or not and history of expulsion of fleshy mass /clots were noted. A detailed clinical examination including complete general physical examination and pelvic examination was done to arrive at a provisional clinical diagnosis.

Patients were then subjected to ultrasound examination. All patients were subjected to transabdominal sonography and transvaginal sonography was preferred whenever transabdominal sonography was inconclusive or equivocal.

Data was collected in a preformed proforma. Clinical and ultrasound findings were correlated. Ultrasonographic evaluation of patients was done using the following machines.

1. Philips IU 22.

2. Samsung medisone.

Transabdominal sonography was done in all cases with 2-6 MHz frequency transducer and transvaginal sonography using 5-7 MHz transducer.

100 cases with history of bleeding per vaginum in the first trimester of pregnancy have been subjected for the study.

OBSERVATION AND RESULT:

In the present study, the majority of patients were from the age group of 26 to 30 years, totaling 44 cases (44%). 28 cases (28%) patients were from age group 31 to 35.15(15%) patients were in age group 20 to 25 years. 8(8%) patients were in age group 36 to 40 years. 5(5%) patients were in age group 41 and above

Present study showing number of cases in different age group and number of viable pregnancies in different age group. Maximum numbers of cases were presented at age group of 25 to 29, and maximum viable pregnancies were also in age group 25-29 years which is 21 cases. Lowest viable rate is found above age 40 years which is 0 percent.

In present study majority of incidence of first trimester bleeding pervaginum is seen in multigravida who comprises 62 cases (62%). Primigravida were only 38 cases (38%) who present with bleeding per vaginum in first trimester.

This study showing incidence of first trimester bleeding is most common during 6 wks to 7+6 wks and comprises 45 cases (45%) and least during 10 wks to 13+6 wks which comprises 23 cases (23%). Incidence of first trimester bleeding is 32 % during 8 wks to 9+6 wks.

This study showing majority of cases with first trimester bleeding diagnosed as threatened abortion and comprises 50 cases (50%) of total 100 cases. Rest 50 cases (50%) includes cases which are complete abortion12 cases (12%), incomplete abortion 5cases (5%), inevitable abortion 2 cases (2%), missed abortion 19 cases (19%) blighted ovum 8 cases (8%), ectopic gestation 3 cases (3%) and complete Mole 1 cases (1%).

The above table and graph shows that out of 86 cases which were clinically diagnosed as threatened abortion, only 50 cases were sonographically confirmed as threatened abortion. There was disparity in 36 cases of threatened abortion which without the aid of ultrasonography would not have received appropriate treatment.

The disparity in case of incomplete abortion was 2 and in missed abortion were 12.

8 cases of Anembryonic gestation and 12 cases of complete abortion were purely a sonographic diagnosis.

The disparity in cases of ectopic was nil, and in case of molar pregnancy disparity was 1.

The total disparity between clinical diagnosis and ultrasound diagnosis was present in 72 cases which accounts to 72%. Out of 100 cases, clinical diagnosis was rightly confirmed by sonography in 64 cases indicating total accuracy of clinical diagnosis to be 64%.

The above table and graph shows that the major cause for bleeding per vaginum in first trimester is abortion. In our study out of 100 cases 96 cases accounting to 96 % had abortion as the major cause of bleeding in first trimester. Rest 4 cases were 3 cases of ectopic pregnancy and 1 case of hydatiform mole.

86 cases clinically diagnosed as threatened abortion, only 50 cases continued as live pregnancy.

Rest 36 cases misdiagnosed clinically were-12 cases of complete abortion, 4 cases of incomplete abortion, 1 case of inevitable abortion, 11 cases of missed abortion and 7 cases were blighted ovum, and 1 Vesicular mole diagnosed on pelvic ultrasonography.

3 cases clinically diagnosed as incomplete abortion, only 1 was confirmed as incomplete abortion. 1 was a case of blighted ovum, and other was a case of missed abortion.

7 cases diagnosed as missed abortion clinically, all 7 confirmed on ultrasonography.

No case of vesicular mole diagnosed clinically.

3 cases of ectopic pregnancy diagnosed clinically were confirmed as ectopic pregnancy on ultrasound.

In the present study, out of 50 cases which were diagnosed as threatened abortion on ultrasound, all 50 cases were continued as normal pregnancy. All other causes of bleeding per vaginum were confirmed on ultrasound.

Out of 100 cases, 62 cases were managed conservatively as 50 cases were diagnose as viable pregnancy on ultrasound and 12 cases were complete abortion on ultrasound.

35 cases underwent instrumental evacuation as they were non-viable.

2 cases underwent laparotomy and 1 case terminated by injection methotrexate.

DISCUSSION: Age group showing maximum incidence of bleeding pervaginum is 26-30 years and constitute 44%. Studies have shown increased risk of abortion with advancing maternal age and parity.

In our study 5 cases were in age 41 and above and all were nonviable pregnancies and hence terminated.

Advancing maternal age is associated with adverse pregnancy outcome, this is also studied by Andrew Cziezel, Zoltan Bognar and Magda Rockenbauer. (7) in their study incidence of spontaneous abortion is 50% after age of 40 years

In study done by Uerpairojkit et al, (8) maximum viable pregnancy rate was obtained in age group 25 to 29 years and it was 49%, which is comparable to our study in which viable pregnancy outcome in age group 25 to 29 years is 48%.

In study done by Uerpairojlit et al, least viability is obtained in age group 40 to 44 years which was 0%, which is similar to present study in which also viability is 0% in age group 40-44 years.

Increase in parity is associated with increased risk of spontaneous abortion and hence first trimester bleeding pervaginum. In present study 62% women were multigravida and 38 percent women primigravida. This is similar to study done by Andrew Cziezel, Zoltan Bognar and Magda Rockenbauer (7) they have also found increase incidence of spontaneous abortion with advancing parity

In present study 45% of patients had bleeding in between 6-8 weeks of gestation which is not comparable to Neelam Bharadwaj study. It is 30% in Neelam Bhardwaj study. (9)

In our study, 32% of cases had bleeding in between 8-10 weeks compared to 35% of Neelam Bharadwaj's study.

In our study 23% had bleeding between 10-13+6 weeks, but this is not comparable because 22% of Neelam Bhardwaj had included cases up to 12 wks only as per old definition.

In our study, all cases of threatened abortion, missed abortion, incomplete abortion, Blighted ovum, Hydatidiform Mole, ectopic gestation, complete abortion and inevitable abortion were diagnosed correctly on ultrasound with an accuracy of 100%. The results of present study are comparable with Rama Sofat (10) and Neelam SB (9) in diagnosing threatened abortion, missed abortion, blighted ovum and H Mole with 100% accuracy.

In present study various abortions contributed to a major chunk of First trimester bleeding constituting 96%. Ectopic pregnancy and H Mole making up the rest of the cases with frequencies of 3% and 1 % respectively, when compared with P. Reddi Rani et al.11 and Rama Sofat et al (10). Study group also abortion is the leading cause of early pregnancy bleeding with an incidence of 61% and 77.5 % respectively

In our study, out of 96 cases of sonologically diagnosed threatened abortion; chorionic bleed was noted in 8 cases;. All 8 cases continued to term gestation. When compared to the Steven R. et al (12) and Jan Fog Pedersen et al, (13) our study has got slightly less incidence of chorionic bleeds.

In our study 100 clinically diagnosed cases were confirmed on ultrasound with disparity of 36%. The present study is not comparable to T G Ghorade's (14) and P Reddi Rani (11) who has got disparity of 50%, 68 % and 42% between clinical and ultrasound diagnosis respectively.

CONCLUSION: Bleeding per vaginum in the first trimester is one of the most common causes for the majority of emergency admissions to the obstetrics department and also vaginal bleeding is most frequent indication of first trimester ultrasonography.

The common causes of bleeding during first trimester include abortions, ectopic pregnancy and molar pregnancy. Ultrasound is a non-invasive, non-ionizing and easily available method of investigation to assess the patients with first trimester bleeding which is highly accurate in diagnosing the actual causes of bleeding and guides the clinician in choosing the appropriate line of management and prevents mismanagement of the cases.

Life threatening emergency like ectopic when evaluated by ultrasound gives scope for conservative approach without affecting the fertility status

RECOMMENDATIONS:

1. All patient presenting with history of first trimester bleeding per vaginum should be attended as emergency as cases like ruptured ectopic can be life threatening.

2. All patients presenting with history of first trimester bleeding per vaginum should be evaluated properly.

3. Clinical examination should include per speculum and per vaginal examination.

4. Pelvic ultrasound is highly recommended in all cases presenting with history of first trimester bleeding for early diagnosis.

Management should be done after confirmation with pelvic ultrasound finding and not merely by clinical findings.

DOI: 10.14260/jemds/2015/1234

REFERENCES:

(1.) Cunningham FG, editor. William's obstetrics 23 edition. New York; McGraw- Hill; 2001. P 195

(2.) Pregnancy, Bleeding.eMedicineHealth.URL: http://www.emedicinehealth.com/pregnancy_bleeding/article_em.htm. Accessed on: April 12, 2009.

(3.) Behera MA, Price TM. Threatened Abortion. eMedicine.com. URL: http: //emedicine.medscape.com/article/266110-overview. Accessed on: April 12, 2009.

(4.) Merritt, CR (1989). "Ultrasound safety: What are the issues?". Radiology 173 (2): 304-6. Doi: 10.1148/radiology.173.2.2678243 (inactive October 31, 2013).

(5.) "Training in Diagnostic Ultrasound: essentials, principles and standards" (PDF). WHO. 1998. p. 2.

(6.) Houston, Laura E.; Odibo, Anthony O.; Macones, George A. (2009). "The safety of obstetrical ultrasound: a review". Prenatal Diagnosis 29 (13): 1204-1212. doi: 10.1002/pd.2392. ISSN 0197-3851.

(7.) Andrew Cziezel, Zoltan Bognar and Magda Rockenbauer Journal of Epidemiology and Community Health, 1984, 38, 143-148.

(8.) Gloria Chiang, Deborah Levine, Michelle Swire, Ann McNamara, Tejas Mehta. The Intradecidual sign: Is it reliable for diagnosis of early intrauterine pregnancy. AJR; 183: 725-731.

(9.) Neelam Bharadwaj. Sonography evaluation as an aid in the management of bleeding in early pregnancy. Journal of obstetrics and Gynecology of India.1988; vol 38: pg 640-642.

(10.) Rama Sofat: ultrasound evaluation of bleeding in early pregnancy. Journal of obstetrics and Gynaecology of India 37, 344: 1987.

(11.) P. Reddirani, V Sunita, Ultrasound Evaluation of cause of vaginal bleeding in first trimester of pregnancy, J Obstet Gynecol Ind Feb 2000; vol.50, No.1: Pg 54-.

(12.) Steven R Goldstein, Bala R Subramaniam, B Nagesh Raghavendra, Steven C Horii, Susan Hilton. Subchorionic bleeding in threatened abortion. Sonographic findings and significance. AJR. Nov 1983; 141: 975-78.

(13.) Jan Fog Pederson, Margit Mantoni. Prevalence and significance of subchorionic hemorrhage in threatened abortion. A sonographic study. AJR. 1990; 154: 535-7.

(14.) Gorade T G: Shorothri A.N.Ultrasonography in early pregnancy bleeding, Journal of obstet and Gynaecol of India, vol 41, 1991 pg 13-16.

Deepti Kurmi [1], Vaishali R. Jadhav [2], Amrita Misri [3], Nigamanada Mishra [4], Santoshi Prabhu [5], Gayatri Savani [6]

AUTHORS:

[1.] Deepti Kurmi

[2.] Vaishali R. Jadhav

[3.] Amrita Misri

[4.] Nigamanada Mishra

[5.] Santoshi Prabhu

[6.] Gayatri Savani

PARTICULARS OF CONTRIBUTORS:

[1.] Resident, Department of Obstetrics & Gynaecology, BARC Hospital, Anushakti Nagar, Mumbai.

[2.] Professor, Department of Obstetrics & Gynaecology, BARC Hospital, Anushakti Nagar, Mumbai.

[3.] HOD, Department of Obstetrics & Gynaecology, BARC Hospital, Anushakti Nagar, Mumbai.

[4.] Professor, Department of Obstetrics & Gynaecology, BARC Hospital, Anushakti Nagar, Mumbai.

[5.] Professor, Department of Obstetrics & Gynaecology, BARC Hospital, Anushakti Nagar, Mumbai.

[6.] Professor, Department of Obstetrics & Gynaecology, BARC Hospital, Anushakti Nagar, Mumbai

FINANCIAL OR OTHER COMPETING INTERESTS: None

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Deepti Kurmi. C/3, Vanshaj Apartment, Pingle Wasti, Mundwa Road, Pune, Maharashtra.

E-mail: ripndip5001@gmail.com

Date of Submission: 28/05/2015. Date of Peer Review: 29/05/2015. Date of Acceptance: 11/06/2015. Date of Publishing: 17/06/2015.
Table 1: Showing Age Distribution of Subjects in The Study

Age               Number   Percentage

20 to 25 years      15         15
26 to 30 years      44         44
31 to 35 years      28         28
36 to 40 years      8          8
41 and above        5          5
TOTAL              100        100

Table 2: Showing Number of Cases and Number of
Viable Cases in Different Age Groups

Age group        Number    Viable    Percentage of
                of Cases   Cases    Viable Cases (%)

20-24 years        9         5            55.5
25-29years         43        21          48.83
30-34years         34        19          55.88
35-39 years        8         6             75
40 -44 years       5         0             0%
45 and above       1         0             0%
Total             100        50            50

Table 3: Showing parity distributions of subjects studied

Parity Distribution   Number   Percentage (%)

Primigravida            38           38
Multigravida            62           62
Total                  100          100

Table 4: Showing distribution of cases according to
period of gestation

Period of             Number of   Percentage
Gestation in weeks      Cases        (%)

6-7+ 6                   45           45
8-9+6                    32           32
10-13+6                  23           23
Total                    100         100

Table 5: Showing distribution of ultrasound findings
in the present study

Ultrasound Diagnosis    Number of Cases   Percentage (%)

Threatened abortion           50                50
Complete abortion             12                12
Incomplete abortion            5                5
Inevitable abortion            2                2
Missed abortion               19                19
Blighted ovum                  8                8
Ectopic pregnancy              3                3
Complete mole                  1                1
Result                        100              100

Table 6: Showing disparity between clinical diagnosis
and ultrasound diagnosis

Cases                  Clinical    Ultrasonography   Disparity
                       Diagnosis      Diagnosis

Threatened abortion       86             50             36
Complete abortion          0             12             12
Incomplete abortion        3              5              2
Inevitable abortion        1              2              1
Missed abortion            7             19             12
Blighted ovum              0              8              8
Ectopic pregnancy          3              3              0
Complete mole              0              1              1
Result                    100            100            72

Table 7: Showing causes of bleeding per vaginum in the
first trimester of pregnancy

Causes               Number   Percentage (%)

Abortion               96           96
Ectopic                3            3
Hydatidiform mole      1            1

Table 8: Follow up of cases diagnosed clinically

Cases                     Number of                Follow up
                       cases diagnosed
                         clinically

Threatened abortion          86          Pregnancy continued-50
                                         Complete abortion-12
                                         Incomplete abortion-4
                                         Inevitable abortion-1
Complete abortion             -          Missed abortion-11
                                         Blighted ovum -7
                                         Vesicular mole-1

Incomplete abortion           3          Incomplete abortion -1
                                         Missed abortion-1
                                         Blighted ovum -1

Blighted ovum                 -          -

Missed abortion               7          Missed abortion-7

Inevitable abortion           1          Inevitable-1

Ectopic gestation             3          All 3 were confirmed on
                                         ultrasonography as ectopic.

Vesicular mole                0          -

Table 9: Showing follow up of cases diagnosed on ultrasound

Cases                  Number of Cases      Follow up of Cases
                        Diagnosed on
                         Ultrasound

Threatened abortion          50              In all 50 cases
                                           pregnancy continued

Complete abortion            12          All cases were confirmed

Incomplete abortion           5          All cases were confirmed

Missed abortion              19          All cases were confirmed

Inevitable abortion           2          All cases were confirmed

Ectopic gestation             3          All cases were confirmed

Vesicular mole                1          All cases were confirmed

Blighted ovum                 8          All cases were confirmed

Table 10: Showing management of cases of first
trimester bleeding

Management                      Number of   Percentage
                                  Cases        (%)

Conservative                       62           62
Instrumental evacuation            35           35
Laparotomy                          2           2
Termination by medical method       1           1
  (inj methotrexate)
Total                              100         100
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Title Annotation:ORIGINAL ARTICLE
Author:Kurmi, Deepti; Jadhav, Vaishali R.; Misri, Amrita; Mishra, Nigamanada; Prabhu, Santoshi; Savani, Gay
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Medical condition overview
Date:Jun 18, 2015
Words:3125
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