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Arch Gynecol Obstet

DOI 10.1007/s00404-013-2979-5

MATERNAL-FETAL MEDICINE

Obstetric outcomes of patients with abortus imminens in the first


trimester
Ayse Nur Evrenos Ayse Nur Cakir Gungor

Cavidan Gulerman Emine Cosar

Received: 17 February 2012 / Accepted: 24 July 2013


Springer-Verlag Berlin Heidelberg 2013

Abstract Conclusions Patients with AI history, especially with


Purpose We aimed to find out the effect of abortus im- high-risk factors can have adverse obstetric and neonatal
minens (AI) on obstetric outcomes of pregnancies which results. So their antenatal follow-up has to be done cau-
continued beyond the 24th week of gestation. tiously for the early signs and symptoms of these
Methods In this prospective study, 309 patients with AI complications.
were divided into high-risk group (with a risk factor for
spontaneous abortus) (n = 92) and low-risk group (without Keywords Abortus imminens  First trimester
a risk factor) (n = 217). The control group (n = 308) was bleeding  Obstetric outcomes  Neonatal outcomes
chosen randomly.
Results In AI group, preterm delivery, preterm premature
rupture of membranes (PPROM), cesarean section (C/S) Introduction
delivery, postpartum uterine atony and need of a neonatal
intensive care unit (NICU) rates were significantly higher Nearly 20 % of all pregnancies are complicated with first
than control group. Gestational diabetes mellitus, PPROM, trimester bleeding which is a risk factor for many com-
still birth, low APGAR scores were seen more frequently in plications [1, 2]. Half of those pregnancies are ended with
the high-risk patients than in the control group. Furthermore spontaneous abortus. Vaginal bleeding with a closed cervix
in the high-risk group, preterm delivery, malpresentation, in early pregnancy is called AI. The diagnosis has to be
C/S delivery and need of NICU were increased much more confirmed with the ultrasonographic imaging of gestational
than in the low-risk group. Gestational hypertension/pre- sac and heart beating embryo or fetus [3].
eclampsia, oligo/polyhydramniosis, intrauterine growth Previous pregnancy loss, still birth and history of baby
retardation, placenta previa, abruption of placenta, chorio- with congenital abnormality increases the fetal loss possi-
amnionitis, congenital abnormalities, delivery induction, bility of the patient with first trimester bleeding. Patients
cephalopelvic disproportion, fetal distress and manual with previous abortus history have 20 % probability of
removal of placenta were not different among the groups. recurrence and three consecutive abortus increases the risk
to 50 %. In addition, maternal systemic diseases such as
A. N. Evrenos  A. N. Cakir Gungor  C. Gulerman DM and thyroid disfunction [4], infertility treatment [5],
Dr. Zekai Tahir Burak Women Health and Research Hospital, maternal and paternal genetic defects [6] and increased
Ankara, Turkey maternal and paternal age [7, 8] are risk factors for spon-
taneous abortus.
A. N. Cakir Gungor  E. Cosar
Canakkale Onsekiz Mart University, Faculty of Medicine, For the treatment of AI many treatments have been tried
Department of Obstetrics and Gynecology, Canakkale, Turkey such as bed rest, restricted sexual intercourse, progester-
ones and human chorionic gonadotropin. But generally
A. N. Cakir Gungor (&)
wait and see management is preferred [9, 10].
Canakkale Onsekiz Mart University Hospital Kepez,
Canakkale, Turkey If the pregnancy continues after AI some obstetric
e-mail: aysenurcakirgungor@gmail.com complications are seen more frequently than usually [11].

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Our aim was to detect whether the gestational compli- Data were analysed with SPSS 11.5 program. To search
cations and obstetric outcomes are effected in case of a the distribution of the continuous variables Shapiro Wilk
pregnancy complicated with AI and continued beyond the test was used. Descriptive statistics for continuous vari-
24th week of gestation. ables were defined as mean standard deviation or
median (minimummaximum). Categorical variables were
expressed as case number and percent. The significance of
Materials and methods the difference of means among groups was analysed by
one-way ANOVA test and the significance of medians
In this study we examined the patients with AI diagnosis was analysed by KruskalWallis test. If a significant dif-
who applied to Dr Zekai Tahir Burak Women Health and ference was found on one-way variance analysis or
Disease Education and Research Hospital antenatal clinic KruskalWallis test, to find the cause of the difference
between 1 September 2009 and 31 December 2009. Ethical post hoc Tukey test or non-parametric multiple analog test
Committee approval and written consent of patients were was used. Categorical variables were searched by Pear-
taken. Patients who were between 6th and 14th week of sons Chi-square test. P \ 0.05 was accepted as statistical
gestation that had gestational sac, embryo or fetus on significance.
ultrasonographic examination and had vaginal bleeding
without cervical dilatation and gynecologic pathology such
as cervical polyps and cervicitis that might cause vaginal Results
bleeding were diagnosed as AI. Pain and hematoma seen in
ultrasound examination were not used as diagnostic crite- In our study there were three groups, a high-risk AI group
ria. We examined 453 patients and divided them into two (n = 92), a low-risk AI group (n = 217) and a control
groups according to having any risk factor prior to or early group (n = 308). Demographic characteristics of the
in pregnancy period for spontaneous abortus as high-risk groups are described in Table 1.
group or not as low-risk group. Multiple pregnancies, The median onset of the bleeding of the patients was 9th
in vitro fertilization (IVF) pregnancies, uterine anomalies, and 10th week of gestation in the high-risk and the low-risk
myoma uteri, cervical insufficiency and recurrent abortus group, respectively.
history were accepted as risk factors. Nearly all patients Abortus history in previous pregnancies was present in
with recurrent abortus history had thrombophilia. Of 453 65.2 % (n = 60) of the high-risk group, 22 % (n = 48) of
patients, 140 of them were in the high-risk group and 313 the low-risk group and 12.3 % (n = 38) of the control
were in the low-risk group. group.
Patients who had spontaneous abortus or intrauterine The distribution of the risk factors in the high-risk group
exitus (n = 31) and patients that could not be followed up is described in Table 2.
(n = 17) were excluded and the remaining 92 patients Factors that might interfere with obstetric outcomes
were included into the high-risk group. such as chronic systemic disease and smoking were not
Patients who had spontaneous abortus or intrauterine significantly different among groups (Table 3).
exitus (n = 51) and patients that could not be followed up Groups were compared according to gestational com-
(n = 45) were excluded and the remaining 217 patients plications in Table 4.
were included into the low-risk group. Pregnancies without complications were seen in 40.2 %
As the control group, 362 patients that applied to our (n = 37) of the high-risk group, 50.2 % (n = 109) of the
antenatal clinic for routine examination at the same time low-risk group and 65.9 % (n = 203) of the control group.
interval and that did not have an AI history in the ongoing Abnormal course of pregnancy was more prevalent in the
pregnancy were chosen randomly. Patients which could not low-risk group (OR 1.9 95 % CI 1.752.13) (P \ 0.001)
be followed up (n = 52) and had spontaneous abortus or and the high-risk group (OR 2.8 95 % CI 2.533.25)
intrauterine exitus (n = 2) were excluded. So, 308 patients (P \ 0.001).
formed the control group. Groups were compared according to their labour char-
In our study, we compared the low-risk and high-risk acteristics in Table 5.
group with control group in respect of maternal age, pre- Gestational age at the labour time was 36.4 (2642) for
vious obstetric history, gestational and delivery complica- the high-risk patients, 38.1 (2542) for the low-risk patients
tions and neonatal outcomes prospectively. We did not use and 38.6 (2742) for the control group (P \ 0.001).
any therapy for AI except bed rest and coitus restriction. Presentation abnormalities were significantly higher in
Only the patients who had recurrent abortus history with the low-risk group when compared with control group (OR
thrombophilia used low molecular weight heparin from the 4.7 95 % CI 3.85.3) and highest in the high-risk group
onset of the pregnancy. (OR 18.7 95 % CI 16.221.1) (P \ 0.001).

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Table 1 Demographic
High-risk group Low-risk group Control group P
characteristics of groups
(n = 92) (n = 217) (n = 308)

Bold values are statistically Maternal age 29.4 5.8 27.4 5.4 26.1 5.4 <0.001a, b, c

significant Gravida 3 (113) 2 (17) 2 (16) <0.001 a, c


a
Control group and high-risk Primigravid 20 (21.7 %) 78 (35.9 %) 109 (35.4 %) 0.034a, c
group difference is statistically
Parity 1 (07) 1 (04) 1 (05) 0.281
significant
b Nulliparous 44 (47.8 %) 90 (41.5 %) 118 (38.3 %) 0.258
Control group and low-risk
group difference is statistically Alive children number 0 (03) 1 (04) 1 (05) 0.079
significant Have a living child 44 (47.8 %) 127 (58.5 %) 187 (60.7 %) 0.088
c
High-risk and low-risk group Abortus 2 (05) 0 (01) 0 (04) <0.001a, c

difference is statistically Curettage 0 (02) 0 (03) 0 (02) 0.934


significant

Table 2 Distribution of risk factors in high-risk group of them had low birth weight, 12 (13 %) of them had both
of the problems. NICU need occurred in 36 (16.6 %) of the
Risk factors High-risk group (n = 92)
low-risk group, 23 (10.6 %) of them had respiratory dis-
Recurrent abortus history 53 (57.6 %) tress, 4 (1.8 %) of them had low birth weight, 6 (2.8 %) of
Multiple pregnancy 29 (31.5 %) them had both of the problems and 3 (1.4 %) of them had
Twin 27 (29.3 %) congenital abnormalities. NICU need occurred in 19
Triplet 2 (2.2 %) (6.2 %) of the control group, 12 (3.9 %) of them had
IVF 24 (26.1 %) respiratory distress, 1 (0.3 %) of them had low birth
Uterine abnormality 2 (2.2 %) weight, 5 (1.6 %) of them had both of the problems and 1
Myoma uteri 5 (5.4 %) (0.3 %) of them had congenital abnormalities.
Cervical 1 (1.1 %) NICU need was significantly higher in the low-risk
group when compared with the control group (OR 3 95 %
CI 2.563.43) and the highest in the high-risk group (OR
5.9 95 % CI 5.216.63) (P \ 0.001).
Table 3 Chronic systemic diseases and smoking properties of groups Etiology of AI is multifactorial. Some risk factors for AI
High-risk Low-risk Control are cervical insufficiency, uterine abnormality, recurrent
group group group abortus history, myoma uteri, multiple pregnancy and IVF
(n = 92) (n = 217) (n = 308) pregnancy. We divided the AI patients into two groups
Chronic systemic disease (%) 12 (13) 14 (6.5) 19 (6.2)
according to the risk factors such as multiple pregnancies
Smoking (%) 4 (4.3) 29 (13.8) 35 (11.4)
which might interfere with the pregnancy outcomes.
Pregnancy complications independent from AI such as
PPROM and NICU might occur because of those risk
C/S delivery ratio was significantly higher in the low- factors. So we tried to exclude this effect by forming a low-
risk group when compared with the control group (OR 1.7 risk group.
95 % CI 1.511.93) and the highest in the high-risk group The prospective design of our study strengthens it, since
(OR 4.9 95 % CI 4.215.52) (P \ 0.0019). But there was by this way a subjective symptom which could be forgotten
no statistically significant difference about cephalopelvic by the patient during the pregnancy is catched correctly
disproportion and fetal distress ratios among the groups. when it occurred. In addition, we marked the risk factors of
Postpartum atony was significantly higher in the low- the patients so that we can clearly understand the effect of
risk group than in the high-risk group (OR 4.7 95 % CI AI independent of the underlying risk factors.
4.215.22) (P \ 0.05). While Basama et al. [2] showed AI prevalence incre-
Low APGAR score was defined as lower than 4 and 7 at ment with age, other studies pointed out that there was no
1st and 5th min, respectively. Low APGAR scores were relationship between them [12, 13]. In our study we also
seen in 14.1 % (n = 13) of the high-risk group, 4.1 % found a relationship between increasing age and AI. Bas-
(n = 9) of the low-risk group and 2.3 % (n = 7) of the ama et al. [2] and Dadkhah et al. [13] found no relationship
control group. This was statistically significant for the between AI and gravida and parity. Although parity was
high-risk group (OR 6.9 95 % CI 6.027.82) (P \ 0.01). not significantly different among the groups in our study,
NICU need occurred in 26 (28.3 %) of the high-risk high-risk patients had more gravity perhaps because of the
group, 8 (8.7 %) of them had respiratory distress, 6 (6.5 %) previous abortus history.

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Table 4 Gestational
High-risk group Low-risk group Control group P
complications of groups
(n = 92) (n = 217) (n = 308)

Hypertension 8 (8.7 %) 15 (6.9 %) 15 (4.9 %) 0.346


Diabetes mellitus 9 (9.8 %) 8 (3.7 %) 7 (2.3 %) 0.005a, b

Oligohydramnios 8 (8.7 %) 15 (6.9 %) 24 (7.8 %) 0.853


Polyhydramnios 1 (1.1 %) 5 (2.3 %) 7 (2.3 %) 0.725
Preterm labour 24 (26.1 %) 23 (10.6 %) 16 (5.2 %) <0.001a, b, c

Bold values are statistically Postterm labour 2 (2.2 %) 6 (2.8 %) 8 (2.6 %) 0.956
significant Membrane rupture 2 (2.2 %) 24 (11.1 %) 17 (5.5 %) 0.007b, c
a
Control group and high-risk PPROM 8 (8.7 %) 14 (6.5 %) 9 (2.9 %) 0.041a

group difference is statistically


IUGR 12 (13.0 %) 20 (9.2 %) 20 (6.5 %) 0.122
significant
b Placenta previa 1 (1.1 %) 1 (0.5 %) 1 (0.3 %) 0.705
High-risk and low-risk group
difference is statistically Placental Decollement 1 (1.1 %) 2 (0.9 %) 0.124
significant Chorioamnionitis 1 (1.1 %) 2 (0.6 %) 0.250
c
Control group and low-risk Intrauterine exitus 3 (3.3 %) 1 (0.5 %) 0 (0 %) 0.011a
group difference is statistically Congenital abnormality 2 (0.9 %) 0.123
significant

Table 5 Labour complications among the groups


High-risk group (n = 92) Low-risk group (n = 217) Control group (n = 308) P

Cephalic presentation 59 (64.1 %) 190 (87.6 %) 299 (97.1 %) <0.001a, b, c

a, b
C/S delivery 70 (76.1 %) 115 (53.0 %) 120 (39.0 %) <0.001
Labour induction 19 (20.7 %) 56 (25.8 %) 77 (25.0 %) 0.616
Retained placenta 1 (1.1 %) 4 (1.8 %) 1 (0.3 %) 0.204
Uterine atony 2 (2.2 %) 10 (4.6 %) 3 (1.0 %) 0.028b
Bold values are statistically significant
a
Control group and high-risk group difference is statistically significant
b
Control group and low-risk group difference is statistically significant
c
High-risk and low-risk group difference is statistically significant

Systemic disease prevalence which might affect obstetric Interestingly, we found a strong relationship between high-
outcomes was not significantly different among the groups. risk AI and gestational DM (OR 4.6). It might be because
Like Mulik et al. [14], we found no significant difference of the older mean age of this group. But this relationship
between the low-risk group and control group about must be investigated by larger well designed controlled
smoking but in the high-risk group smoking rates were prospective studies.
lower than in the other groups. Perhaps it was because of the If the placentation site in the early pregnancy is placed
responsive attitude of those patients due to their risk factors. inferiorly, first trimester bleeding and placenta previa is
Because of the possible effect of bleeding on placental more prevalent. Wijesiriwardana et al. [12] found 1.8
dysfunction it was thought that there might be a relation- times, Mulik et al. [14] found 3.3 times and Obed et al. [16]
ship between AI and gestational hypertensive diseases. In a found 2.5 times increase in placenta previa prevalence in
multicenter prospective study, Weiss et al. [11] found that patients with AI history. But Davari-Tanha et al. [17] found
there was a relationship between AI and preeclampsia (OR no difference between AI group and control group about
1.5). On the other hand Wijesiriwardana et al. [12] and placenta previa prevalence in his prospective study. We
Dadkhah et al. [13] found no relationship between them. also did not found any significant difference about placenta
We also did not find a relationship between gestational previa among groups.
hypertensive conditions and AI. AI caused placental disfunction which might lead to
Adverse obstetric outcomes can be seen in gestational placental decollement. Mulik et al. [14], Obed et al. [16]
DM and pre pregnancy DM, especially in the uncontrolled and Johns et al. [18] found increment in placental
ones. A retrospective study by Ahkter et al. [15] found decollement in AI patients. But Wijesiriwardana et al. [12]
increment in AI rates in diabetic pregnants (OR 1.4). did not find increased risk for placental decollement for AI

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patients. We also did not found any significant difference and AI which might be because of the small sample size of
about placenta previa among groups. This might be the study.
because of the small sample size of our study. Although Wijesiriwardana et al. [12] found no rela-
Bleeding, disrupted chorioamniotic space, infection tionship between postpartum atonia and AI, we showed a
caused by hematoma and decrement of cytotrophoblastic 4.7 times increase in the low-risk group but not in the high-
invasion by spiral arterioles might induce preterm labour risk group. Increment of uterine atonia in the low-risk
and PPROM in AI patients. Various studies showed group might be a sign of common steps in the patho-
increased risk of preterm labour for AI [11, 12, 14, 18]. We physiology of AI and also uterine atony. So this is the most
found 2.1 times increase in low-risk patients and 6.4 times striking result of our study.
increase in high-risk patients for preterm labour. While Tongsongs study showed a 1.2 times increase in low
some studies found increment of PPROM risk for those APGAR scores in AI patients [19]. In Wijesiriwardanas
patients [1, 13, 18], the others found no relationship study there was a 1.13 times increase in NICU need [12].
between AI and PPROM [14, 19]. We found a mild Spila et al. [20] found no relations between NICU need and
increase for low-risk group that had no significance for AI. We did not found a relationship between the low-risk
PPROM but a 3.2 times increase for high-risk group was group and the control group in terms of low APGAR scores.
determined. It might be because of the underlying risk But 6.9 times increased low APGAR scores were determined
factors of those patients. in the high-risk group. This increment might be because of
Scar tissue formation beneath the placenta of AI patient lower gestational age of this group. Need to NICU caused
might cause IUGR. While Dadkhah et al. [13] and Tong- mostly by respiratory distress increased 3 times in the low-
song et al. [19] showed no difference, Mulik et al. [14] risk group and need to NICU usually because of prematurity
found 2.5 times increase for IUGR. We also found no increased 5.9 times in the high-risk group.
relationship between AI and IUGR. Limitations of the current study are the absence of hema-
Like the former studies we did not find relationship toma finding in the ultrasound image, amount and recurrence
between congenital anomalies and AI [19]. Perinatal of the bleeding and infections complicating the pregnancy that
mortality of AI patients was increased 2.8 times in Muliks might cause preterm labour which might lead to neonatal
study and 7.6 times in Davari-Tanhas study [14, 17]. But complications. The objective parameter of fetal outcome pH
in some studies there were no relationship between peri- was not examined in our study. Instead we evaluated the
natal mortality and AI [12, 20]. We did not record the APGAR scores and NICU need for the newborn.
perinatal mortality instead we found a 3.1 times increment In conclusion, independent of the bleeding amount AI
in intrauterine exitus in high-risk group. patients have increased risk of adverse perinatal neonatal
Mean gestational age at term was lowest in high-risk outcomes; moreover, if the patient has risk factors prior to
group because of the preterm births and PROM. While or early in the pregnancy perinatal outcomes might be
Wijesiriwardana et al. [12] found a 1.3 times increase in worser and the patient and the doctor must be very careful
fetal malpresentation in AI group we found 4.7 times about those adverse outcomes.
increase in low-risk group and a 18.7 times in high-risk
group. This finding might be because of the underlying risk Conflict of interest We declare that we have no conflict of interest.
factors of those patients.
Like Wijesiriwardana et al. [12] we did not found a rela-
tionship between labour induction and AI. Weiss et al. [11] References
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