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DOI 10.1007/s00404-013-2979-5
MATERNAL-FETAL MEDICINE
Received: 17 February 2012 / Accepted: 24 July 2013 / Published online: 4 August 2013
Springer-Verlag Berlin Heidelberg 2013
Abstract
Purpose We aimed to find out the effect of abortus imminens (AI) on obstetric outcomes of pregnancies which
continued beyond the 24th week of gestation.
Methods In this prospective study, 309 patients with AI
were divided into high-risk group (with a risk factor for
spontaneous abortus) (n = 92) and low-risk group (without
a risk factor) (n = 217). The control group (n = 308) was
chosen randomly.
Results In AI group, preterm delivery, preterm premature
rupture of membranes (PPROM), cesarean section (C/S)
delivery, postpartum uterine atony and need of a neonatal
intensive care unit (NICU) rates were significantly higher
than control group. Gestational diabetes mellitus, PPROM,
still birth, low APGAR scores were seen more frequently in
the high-risk patients than in the control group. Furthermore
in the high-risk group, preterm delivery, malpresentation,
C/S delivery and need of NICU were increased much more
than in the low-risk group. Gestational hypertension/preeclampsia, oligo/polyhydramniosis, intrauterine growth
retardation, placenta previa, abruption of placenta, chorioamnionitis, congenital abnormalities, delivery induction,
cephalopelvic disproportion, fetal distress and manual
removal of placenta were not different among the groups.
A. N. Evrenos A. N. Cakir Gungor C. Gulerman
Dr. Zekai Tahir Burak Women Health and Research Hospital,
Ankara, Turkey
A. N. Cakir Gungor E. Cosar
Canakkale Onsekiz Mart University, Faculty of Medicine,
Department of Obstetrics and Gynecology, Canakkale, Turkey
A. N. Cakir Gungor (&)
Canakkale Onsekiz Mart University Hospital Kepez,
Canakkale, Turkey
e-mail: aysenurcakirgungor@gmail.com
Introduction
Nearly 20 % of all pregnancies are complicated with first
trimester bleeding which is a risk factor for many complications [1, 2]. Half of those pregnancies are ended with
spontaneous abortus. Vaginal bleeding with a closed cervix
in early pregnancy is called AI. The diagnosis has to be
confirmed with the ultrasonographic imaging of gestational
sac and heart beating embryo or fetus [3].
Previous pregnancy loss, still birth and history of baby
with congenital abnormality increases the fetal loss possibility of the patient with first trimester bleeding. Patients
with previous abortus history have 20 % probability of
recurrence and three consecutive abortus increases the risk
to 50 %. In addition, maternal systemic diseases such as
DM and thyroid disfunction [4], infertility treatment [5],
maternal and paternal genetic defects [6] and increased
maternal and paternal age [7, 8] are risk factors for spontaneous abortus.
For the treatment of AI many treatments have been tried
such as bed rest, restricted sexual intercourse, progesterones and human chorionic gonadotropin. But generally
wait and see management is preferred [9, 10].
If the pregnancy continues after AI some obstetric
complications are seen more frequently than usually [11].
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500
Our aim was to detect whether the gestational complications and obstetric outcomes are effected in case of a
pregnancy complicated with AI and continued beyond the
24th week of gestation.
123
Results
In our study there were three groups, a high-risk AI group
(n = 92), a low-risk AI group (n = 217) and a control
group (n = 308). Demographic characteristics of the
groups are described in Table 1.
The median onset of the bleeding of the patients was 9th
and 10th week of gestation in the high-risk and the low-risk
group, respectively.
Abortus history in previous pregnancies was present in
65.2 % (n = 60) of the high-risk group, 22 % (n = 48) of
the low-risk group and 12.3 % (n = 38) of the control
group.
The distribution of the risk factors in the high-risk group
is described in Table 2.
Factors that might interfere with obstetric outcomes
such as chronic systemic disease and smoking were not
significantly different among groups (Table 3).
Groups were compared according to gestational complications in Table 4.
Pregnancies without complications were seen in 40.2 %
(n = 37) of the high-risk group, 50.2 % (n = 109) of the
low-risk group and 65.9 % (n = 203) of the control group.
Abnormal course of pregnancy was more prevalent in the
low-risk group (OR 1.9 95 % CI 1.752.13) (P \ 0.001)
and the high-risk group (OR 2.8 95 % CI 2.533.25)
(P \ 0.001).
Groups were compared according to their labour characteristics in Table 5.
Gestational age at the labour time was 36.4 (2642) for
the high-risk patients, 38.1 (2542) for the low-risk patients
and 38.6 (2742) for the control group (P \ 0.001).
Presentation abnormalities were significantly higher in
the low-risk group when compared with control group (OR
4.7 95 % CI 3.85.3) and highest in the high-risk group
(OR 18.7 95 % CI 16.221.1) (P \ 0.001).
501
Table 1 Demographic
characteristics of groups
Bold values are statistically
significant
a
Maternal age
High-risk group
(n = 92)
Low-risk group
(n = 217)
Control group
(n = 308)
29.4 5.8
27.4 5.4
26.1 5.4
<0.001a,
Gravida
3 (113)
2 (17)
2 (16)
<0.001
Primigravid
20 (21.7 %)
78 (35.9 %)
109 (35.4 %)
0.034a,
Parity
1 (07)
1 (04)
1 (05)
0.281
Nulliparous
44 (47.8 %)
90 (41.5 %)
118 (38.3 %)
0.258
0 (03)
1 (04)
1 (05)
0.079
44 (47.8 %)
127 (58.5 %)
187 (60.7 %)
0.088
Abortus
2 (05)
0 (01)
0 (04)
<0.001a,
Curettage
0 (02)
0 (03)
0 (02)
0.934
Risk factors
53 (57.6 %)
Multiple pregnancy
29 (31.5 %)
Twin
27 (29.3 %)
Triplet
2 (2.2 %)
IVF
24 (26.1 %)
Uterine abnormality
2 (2.2 %)
Myoma uteri
5 (5.4 %)
Cervical
1 (1.1 %)
12 (13)
4 (4.3)
Low-risk
group
(n = 217)
Control
group
(n = 308)
14 (6.5)
19 (6.2)
29 (13.8)
35 (11.4)
C/S delivery ratio was significantly higher in the lowrisk group when compared with the control group (OR 1.7
95 % CI 1.511.93) and the highest in the high-risk group
(OR 4.9 95 % CI 4.215.52) (P \ 0.0019). But there was
no statistically significant difference about cephalopelvic
disproportion and fetal distress ratios among the groups.
Postpartum atony was significantly higher in the lowrisk group than in the high-risk group (OR 4.7 95 % CI
4.215.22) (P \ 0.05).
Low APGAR score was defined as lower than 4 and 7 at
1st and 5th min, respectively. Low APGAR scores were
seen in 14.1 % (n = 13) of the high-risk group, 4.1 %
(n = 9) of the low-risk group and 2.3 % (n = 7) of the
control group. This was statistically significant for the
high-risk group (OR 6.9 95 % CI 6.027.82) (P \ 0.01).
NICU need occurred in 26 (28.3 %) of the high-risk
group, 8 (8.7 %) of them had respiratory distress, 6 (6.5 %)
b, c
a, c
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502
Table 4 Gestational
complications of groups
High-risk group
(n = 92)
Low-risk group
(n = 217)
Control group
(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,
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,
Postterm labour
2 (2.2 %)
6 (2.8 %)
8 (2.6 %)
Membrane rupture
2 (2.2 %)
24 (11.1 %)
17 (5.5 %)
PPROM
IUGR
8 (8.7 %)
14 (6.5 %)
9 (2.9 %)
0.041
20 (9.2 %)
20 (6.5 %)
0.122
1 (1.1 %)
1 (0.5 %)
1 (0.3 %)
0.705
Placental Decollement
Chorioamnionitis
1 (1.1 %)
1 (1.1 %)
2 (0.9 %)
2 (0.6 %)
0.124
0.250
Intrauterine exitus
3 (3.3 %)
1 (0.5 %)
0 (0 %)
0.011a
2 (0.9 %)
12 (13.0 %)
b, c
0.956
0.007b,
Placenta previa
Congenital abnormality
0.123
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
123
Interestingly, we found a strong relationship between highrisk AI and gestational DM (OR 4.6). It might be because
of the older mean age of this group. But this relationship
must be investigated by larger well designed controlled
prospective studies.
If the placentation site in the early pregnancy is placed
inferiorly, first trimester bleeding and placenta previa is
more prevalent. Wijesiriwardana et al. [12] found 1.8
times, Mulik et al. [14] found 3.3 times and Obed et al. [16]
found 2.5 times increase in placenta previa prevalence in
patients with AI history. But Davari-Tanha et al. [17] found
no difference between AI group and control group about
placenta previa prevalence in his prospective study. We
also did not found any significant difference about placenta
previa among groups.
AI caused placental disfunction which might lead to
placental decollement. Mulik et al. [14], Obed et al. [16]
and Johns et al. [18] found increment in placental
decollement in AI patients. But Wijesiriwardana et al. [12]
did not find increased risk for placental decollement for AI
503
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