Indentification of the causes of first trimester vaginal bleeding and fetomaternal outcomes in cases with threatened abortion

Introduction

Pregnancy and childbirth are the significant events in a woman’s life which accord her the status of motherhood. Pregnancy can be a time of great hope and blissful expectations. However in certain cases it can be a period of terror, pain and even death. Pregnancy is a physiological process when one or more off springs develop inside a woman’s womb. A pregnancy may end in a live birth, a spontaneous miscarriage (spontaneous abortion), an induced abortion, or a stillbirth.

About 25% of women will have first-trimester bleeding, and about half of those women will have a spontaneous abortion and approximately 50% will go on to have a normal pregnancy. Meta- analysis suggests that the first trimester vaginal bleeding doubles the risk of other pregnancy complications.^[1] Major causes of first trimester bleeding are miscarriage (threatened, inevitable, complete or incomplete), ectopic pregnancy, implantation bleeding, molar pregnancy and cervical pathology.^[2] The risk of impending abortion increases with maternal age, systemic disorders like hypothyroidism and diabetes mellitus, infertility treatments, maternal weight, thrombophilia, and uterine anatomical abnormalities.^[3], ^[4] First-trimester bleeding leads to pregnancy loss in over 50% of cases. Threatened miscarriage is identified in presence of fetal cardiac activity on ultrasonography with complain of bleeding per vaginum with closed cervical os on examination. Bleeding per vaginum during early pregnancy may be related to poor feto-maternal outcomes.^[5] Potential adverse outcomes include preterm premature rupture of membranes (PPROM), preterm delivery (PTL), placental abruption, intrauterine growth restriction (IUGR), and pre-eclampsia.^[6], ^[7] It is hypothesized that first trimester bleeding may indicate an underlying placental dysfunction which may manifest later on in pregnancy causing adverse pregnancy outcomes as mentioned earlier.^[5] Comprehensive understanding about pregnancy outcome following 1^st trimester vaginal bleeding is important not only to pregnant mothers, but also to the obstetrician treating her; to plan adequate antenatal care and timely intervention to reduce the maternal and perinatal complications. To evaluate adverse fetal outcomes following first trimester vaginal bleeding, several studies have been attempted, but a couple of them have remarked on adverse maternal outcome.

This study aimed to find out the various causes of first trimester vaginal bleeding and to evaluate the foeto-maternal outcome in threatened abortion in the pregnant females.

Materials and Methods

Results

Total of 133 females were enrolled for the study out of which 31 lost to follow up. Data of 102 females was collected and results were compiled as follows.

Majority 41(40.20%) of the cases were of 26 -30 years and least number 06(5.88%) of cases of study were present in the age group >35 years as depicted in [Table 1]. The mean age of the patients of the study was 27.78 years ± 3.483.

The majority 33(32.35%) cases belonged to lower middle class followed by upper lower class which had 26 (25.49%) cases. Only two (1.96%) cases were from upper socioeconomic status.

72(70.59%) cases were Multigravida out of which 20(19.6%) patients had history of previous abortion, and 30(70.59) were primigravida.

Out of total 102 cases, majority 54(52.94%) cases had gestational age of 7 to 10 weeks at the time of bleeding per vaginum as depicted in [Table 1]. Mean age = 9.52+/- 2.76 weeks.

Out of total 8 ectopic pregnancy patients that presented with bleeding, 6 of them presented at 7-10 weeks of gestation and 2 presented at <7 weeks of gestation.

In majority 59(57.84%) cases, the bleeding was moderate to heavy while in 43 (42.16%) only spotting was present as shown in [Table 2].

Overall patients who presented with spotting, majority of them continued their pregnancy as seen in this study.

Majority of the cases 53(51.96%) were diagnosed with threatened abortion followed by missed abortion in 19 (18.62%) patients. Incomplete abortion in 14 (13.72%) cases incomplete, ectopic pregnancy in 08(7.85%), complete abortion in 04 (3.92%), inevitable abortion in 03(2.51%) and one (0.98%) case of molar pregnancy. These causes of first trimester vaginal bleeding has been summarized in [Table 3].

Distribution of cases with first trimester bleeding on the basis of management as depicted in [Table 4]. Majority 57(55.88%) cases were managed conservatively while in 15 (14.72%) cases medical management was done. In 14 (13.72%) cases Dilatation and evacuation was done and in 08(7.4%) cases Suction and evacuation. Laparotomy was needed in 8(7.84%). Out of total 102 patients 15(14.7%) cases required blood transfusion and ICU stay was needed in 06(5.88%) cases.

[Table 5] depicts the distribution of cases on the basis of maternal outcome of threatened abortion. In 26 (49.056%) cases preterm delivery took place while 24 cases (45.28%) delivered at term, out of which 4(7.574%) were IUFD. Other outcomes which overlapped included PPH in 02(3.773%), PIH in 06(11.320%), placenta previa in 11(20.754%), abruptio placenta in 7(13.2%) and PROM 19(35.85%). Second trimester abortion was seen in 3 cases (5.66%).

Majority 35(70%) cases delivered vaginally while in 15 (30%) cases, mode of delivery was C-section.

In the present study neonates with APGAR score < 7 at 1 min were 15(41.31%). Out of total 46 live births, 27(58.69%) case were low birth weight babies and 19(41.31%) required NICU admission. IUFD in 4 cases (7.547%) as depicted in [Table 6].

Discussion

During the first trimester, vaginal bleeding emerges as an important concern in obstetrics requiring urgent attention and at times hospital care as IPD. In such pregnancies, maternal and fetal wellbeing is compromised. Therefore it is important to delineate such patients in early pregnancy stages so that they can be managed timely.

In the present study, majority 41 cases (40.20%) fell in age group of 26 -30 years followed by 21 -25 years with 25(24.51%) cases. Least number of cases 06(5.88%) were seen in >35 years of age as seen in [Table 1]. The mean age of the patients of the study is 27.78 years ± 3.483. The findings of the study are similar with studies conducted by Arora et al^[13] where the majority females (47.3%) of the study were from the age group of 26 to 30 years and Madhurima et al^[14] where majority (27.9%) patients belonged to 25 -29 years age group.

In the present study, majority 72(70.59%) cases were Multigravida and 30(29.41%) were primigravida. The findings were similar with the study conducted by Suganya et al^[15] which showed 30% primigravida and 70% multigravida. The studies which had different results were Mudhurima et al^[14] with 57.5% primigravida and 42.5% multigravida.

In this study, in majority 59(57.84%) cases, the bleeding was moderate to heavy while in 43(42.16%) cases only spotting was present. The findings were similar to the studies conducted by Amirkhani et al^[16] where spotting was seen in 3.3% cases while in 96.7% bleeding was moderate to severe and Chandramathi et al^[17] where there were only 2% cases of spotting while 80% had moderate and 18% had severe bleeding.

In this study among 72 multigravida patients, previous history of abortion was present in 20 (19.61%) cases. The finding of the present study can be compared with studies conducted by Chandramathi et al^[17] where previous history of abortion was present in 16% cases. Study conducted by El Raheem et al^[18] showed 45.5% cases had previous history of abortion

From total of 102 cases, majority of the patients 54(52.94%) had gestational age of 7 to 10 weeks at the time of presentation with first trimester bleeding with the mean age 9.52 ± 2.76. The findings of the study can be compared with studies conducted by Madhurima et al^[14] where the 80.3% patients had bleeding in less than 14 weeks while 19.7% had bleeding at more than 14 weeks and El Raheem et al^[18] where the mean gestational age of presentation with bleeding was 13.44 ± 1.63 weeks. In another study by Sarmalkar et al^[19] where mean gestational age is 8 ± 11.9.weeks.

In the study, most of the cases 53(51.96%) had threatened abortion followed by missed abortion in 19(18.62%) cases, incomplete abortion in 14(13.72%), ectopic pregnancy in 8(7.85%), complete abortion in 04 (3.92%), inevitable abortion in 03(2.51%) and one (0.98%) case of molar pregnancy. Findings of this study can be compared with various studies as in [Table 7].

In this study out of the total 53 cases with threatened abortion, majority of the cases 26(49.06%) had normal ultrasonography findings while in 16(30.19%) cases USG showed sub chorionic haemorrhage and in 11 (20.75%) cases there was low lying placenta. The findings can be compared with studies conducted by Sayyad et al^[12] where in 7.3% cases there was sub chorionic hematoma. In the study conducted by Agarwal et al^[20] observed sub chorionic haemorrhage in 43.55% cases.

In the present study majority 57(55.88%) cases were managed conservatively, 15 (14.72%) cases required medical management, 14 (13.72%) cases required Dilatation and evacuation, 08(7.84%) cases needed Suction and evacuation and 8 (7.84%) cases required laparotomy. 14.7 cases required blood transfusion. The findings of the present study can be compared with studies conducted by Ahmad et al^[11] where the conservative treatment was done in 56% cases. In another study, conducted by Sayyad et al^[12] 16.15% cases were conservatively managed, 73.8% cases underwent uterine curettage and rest of the cases were managed medically. 2.4% cases required blood transfusion.

The present study observed the maternal outcomes of threatened abortion. In 3 (5.66%) cases second trimester complete abortion was observed. In 26(49.056%) cases preterm delivery took place while in 20(37.74%) cases delivered at term. Other outcomes which overlapped one another included PROM in 19(35.85%) cases, PPH in 02(3.773%), PIH in 06(11.320%) and IUFD in 04(7.574%) cases. Placenta previa was present in 11(20.754%) cases and Abruptio placenta was present in 07(13.207%) cases. The findings of the present study can be compared with studies conducted by Arora et al^[13] where it was observed that out of patients who continued pregnancy, 17.3% developed hypertensive disorders such as gestational hypertension, preeclampsia and eclampsia, 21.3% patients had either premature rupture of membranes or pre-term premature rupture of membranes, 12% patients had post-partum haemorrhage. 76.0% patients had one or the other complication in pregnancy. In the study conducted by Bhatti et al^[21] preterm delivery took place in 32.25% cases, other maternal outcomes included placenta previa in 8.16%, premature preterm rupture of membranes and antepartum haemorrhage was present in 18.37%. Another study by Kanmaz et al^[22] which observed preeclampsia in 3.8%, placenta previa in 0.8% and abruptio placenta was present in 0.4% cases. Karimi et al.^[23] conducted a systematic review and meta-analysis to investigate the relationship between first trimester vaginal bleeding and various clinical adverse outcomes. The meta-analysis included 46 relevant studies with sample size of 1,554,141. The presence of vaginal bleeding in the first trimester of pregnancy significantly correlates with an increased risk of adverse pregnancy outcomes, including preterm birth, low birth weight, premature rupture of membranes, miscarriage, stillbirth, placental abruption, and placenta previa.

In the present study, majority 35(70%) cases delivered vaginally while in 15 (30%) cases, mode of delivery was C-section. The findings of the present study are similar to the studies conducted by Madhurima et al^[14] where 63.45 delivered vaginally and 36.6% delivered through C section.

In the present study, 27(58.69%) babies out of total 46 cases weighed less than 2.5 kg and 19(41.31%) babies weighed more than equal to 2.5 Kg at the time of birth. The findings of the present study are different from the studies conducted by Chaitanya et al^[15] where 77% cases the birth weight was more than 2.5Kg while in 23% cases it was low birth weight and Chandramathi et al^[17] where the birth weight of more than 2.5Kg was observed in 73% cases while 27% cases had low birth weight.

In the present study it was observed that 27(58.69%) cases out of total 46 did not require NICU admission. The findings can be compared with the study conducted by Arora et al^[13] where 34.7% newborns required NICU admission.

In this study 31(67.39%) babies had APGAR score more than seven at 1 min while 15 (32.61%) had less than seven. The findings can be compared with studies conducted Bhatti et al^[21] which observed that an APGAR score at 1 min of <7 was seen in 6.52% of cases while in 35% it was 7. In another study by Madhurima et al^[17] where APGAR score less than 7 was observed in 11.2% cases.

Conclusion

The study indicated that first trimester vaginal bleeding is a prevalent and a concerning occurrence necessitating thorough evaluation to identify the underlying causes like – miscarriage, threatened abortion, ectopic pregnancy, molar pregnancy etc. as such bleeding episodes are linked to suboptimal maternal and fetal outcomes. Notable various complications may ensue in women that continue pregnancy with bleeding in first trimester like- preterm labour, premature rupture of membranes, placenta previa, abruptio placenta, PIH, fetal growth restriction and PPH. As threatened abortion is a precursor to adverse maternal and fetal outcomes thereby emphasizing the importance of ensuring diligent follow up care. Patients with first trimester bleeding should be categorized as high risk patients and be monitored actively during antenatal period with appropriate management strategies in place.

Source of Funding

None.

Conflict of Interest

None.