The Effect of Vaginal Bleeding in Early Pregnancy on First Trimester Screening Test, Uterine Artery Doppler Indices and Perinatal Outcomes

Öz

Aim: We aimed to prospectively investigate the effect of first trimester vaginal bleeding on first trimester screening test, uterine artery (UtA) Doppler results and perinatal outcomes. Material and Methods: Fifty cases that presented with vaginal bleeding in the first trimester between 2019 and 2020 constituted the early vaginal bleeding (abortus imminens-threatened abortion) group and fifty cases without a history of vaginal bleeding in pregnancy constituted the control group. Demographic datas were noted at the first visit. Both groups were followed up until birth. First trimester screening test (double screening test) between 11-14 weeks and UtA Doppler examination between 20-24 weeks of gestation was performed. Perinatal outcomes and values of nuchal translucency (NT), free β human chorionic gonadotropin (f β-hCG), pregnancy-associated plasma protein A (PAPP-A), and UtA Doppler were compared between the two groups. Results: There was no statistically significant difference was found between the two groups in terms of NT and PAPP-A among the first trimester screening test results (p=0.741 and p=0.937, respectively). In the group with threatened miscarriage, f β-hCG value was numerically higher, but there was no statistically significant difference (1.24±0.59 vs. 1.1±0.93, p=0.057). In the Doppler examination of the UtA, there was no statistically significant difference between the groups in terms of systolic/diastolic ratio, pulsatility index, resistive index and the presence of a notch (p=0.713, p=0.528, p=424, p=0.538, respectively). Perinatal complication rate was statistically significantly higher in the study group (p=0.013; Odds Ratio:3.2, 95% CI 1.2-8.3). Conclusion: Contrary to some different studies, we believe that first trimester screening test parameters or uterine artery Doppler flow indices do not have a place in predicting perinatal outcomes of pregnant women with a history of vaginal bleeding in the first trimester. In addition, early vaginal bleeding does not significantly affect screening parameters. Perinatal complication rate was found to be statistically significantly higher in the group with a history of threatened miscarriage.

Anahtar Kelimeler

• Doppler
• uterine artery
• abortus imminens
• threatened abortion
• vaginal bleeding
• first trimester

Erken Gebelikte Vajinal Kanamanın İlk Trimester Tarama Testi, Uterin Arter Doppler İndeksleri ve Perinatal Sonuçlara Etkisi

Öz

Amaç: Bu çalışmada birinci trimesterde görülen vajinal kanamanın birinci trimester tarama testi, uterin arter (UtA) Doppler sonuçları ve perinatal sonuçlara etkisini prospektif olarak araştırmayı amaçladık. Gereç ve Yöntem: 2019-2020 yılları arasında ilk trimesterde vajinal kanama ile başvuran elli olgu erken gebelik kanaması (abortus imminens-düşük tehditi) grubunu, gebelikte vajinal kanama öyküsü olmayan elli olgu ise kontrol grubunu oluşturdu. Demografik veriler ilk ziyarette not edildi. Her iki grup doğuma kadar takip edildi. 11-14. haftalar arasında birinci trimester tarama testi (ikili tarama testi) ve 20-24. gebelik haftaları arasında UtA Doppler incelemesi yapıldı. Ense saydamlığı (NT), serbest beta-insan koryonik gonadotropini (f β-hCG), gebelikle ilişkili plazma protein-A (PAPP-A) ve UtA Doppler'in değerleri ve perinatal sonuçlar iki grup arasında karşılaştırıldı. Bulgular: Birinci trimester tarama testinde bakılan NT ve PAPP-A açısından iki grup arasında istatistiksel olarak anlamlı fark bulunmadı (sırasıyla p=0.741 ve p=0.937). Abortus imminens grubunda f β-hCG değeri sayısal olarak belirgin yüksekti ancak sonuçlar istatistiksel olarak anlamlı anlamlı değildi (1.24±0.59 vs. 1.1±0.93, p=0.057). Uterin arterin Doppler incelemesinde sistol/diyastol oranı, pulsatilite indeksi, direnç indeksi ve çentik varlığı açısından gruplar arasında istatistiksel olarak anlamlı fark yoktu. (sırasıyla p=0.713, p=0.528, p=424, p=0.538). Perinatal komplikasyon oranı çalışma grubunda anlamlı olarak yüksekti (p = 0.013; Odds Ratio: 3.2, %95 GA 1.2 - 8.3). Sonuç: Literatürde ki bazı farklı çalışmaların aksine birinci trimester tarama testi parametrelerinin veya uterin arter Doppler akım indekslerinin ilk trimesterde vajinal kanama öyküsü olan gebelerin perinatal sonuçlarını öngörmede yeri olmadığını düşünüyoruz. Ayrıca erken gebelik kanaması, tarama parametrelerini önemli ölçüde etkilememektedir. Abortus imminens grubunda perinatal komplikasyon oranı istatistiksel olarak anlamlı derecede yüksetir.

Anahtar Kelimeler

• Doppler
• uterin arter
• abortus imminens
• düşük tehditi
• vajinal kanama
• ilk trimester

Kaynakça

1. 1. ACOG Committee Opinion #296: first-trimester screening for fetal aneuploidy. Obstet Gynecol. 2004 Jul;104(1):215–7.
2. 2. Republic of Turkey Ministry of Health. PRENATAL CARE MANAGEMENT GUIDE. Ankara, 2018.
3. 3. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics, Committee on Genetics, Society for Maternal-Fetal Medicine. Screening for Fetal Chromosomal Abnormalities: ACOG Practice Bulletin, Number 226. Obstet Gynecol. 2020 Oct;136(4):e48–69.
4. 4. Salomon LJ, Alfirevic Z, Berghella V, Bilardo CM, Chalouhi GE, Da Silva Costa F, et al. ISUOG Practice Guidelines (updated): performance of the routine mid-trimester fetal ultrasound scan. Ultrasound Obstet Gynecol. 2022;59(6):840–56.
5. 5. Parry S, Sciscione A, Haas DM, Grobman WA, Iams JD, Mercer BM, et al. Role of early second-trimester uterine artery Doppler screening to predict small-for-gestational-age babies in nulliparous women. Am J Obstet Gynecol. 2017 Nov;217(5):594.e1-594.e10.
6. 6. Papageorghiou AT, Yu CKH, Cicero S, Bower S, Nicolaides KH. Second-trimester uterine artery Doppler screening in unselected populations: a review. J Matern-Fetal Neonatal Med Off J Eur Assoc Perinat Med Fed Asia Ocean Perinat Soc Int Soc Perinat Obstet. 2002 Aug;12(2):78–88.
7. 7. Hasan R, Baird DD, Herring AH, Olshan AF, Jonsson Funk ML, Hartmann KE. Association Between First-Trimester Vaginal Bleeding and Miscarriage: Obstet Gynecol. 2009 Oct;114(4):860–7.
8. 8. Hasan R, Baird DD, Herring AH, Olshan AF, Jonsson Funk ML, Hartmann KE. Patterns and Predictors of Vaginal Bleeding in the First Trimester of Pregnancy. Ann Epidemiol. 2010 Jul;20(7):524–31.

9. 9. Vardhan S, Bhattacharyya T, Kochar S, Sodhi B. Bleeding in Early Pregnancy. Med J Armed Forces India. 2007 Jan;63(1):64–6.
10. 10. Erol SA, Altinboga O, Yakistiran B, Halici Ozturk F, Baser E, Caglar AT. Evaluation of Actual Maternal Serum Alpha-Fetoprotein (MSAFP) Levels in Placental Abruption and Associations with Adverse Outcomes. SN Compr Clin Med. 2021 Feb 1;3(2):611–7.
11. 11. Mor A, Tal R, Haberman S, Kalgi B, Nasab SH, Minkoff H. Same-day confirmation of intrauterine pregnancy failure in women with first- and early second-trimester bleeding. Fertil Steril. 2018 Jun 1;109(6):1060–4.
12. 12. De Biasio P, Canini S, Crovo A, Prefumo F, Venturini PL. Early vaginal bleeding and first-trimester markers for Down syndrome. Prenat Diagn. 2003 Jun;23(6):470–3.
13. 13. Heinig J, Steinhard J, Schmitz R, Nofer JR, Witteler R, Mosel A, et al. Does vaginal bleeding influence first-trimester markers for Down syndrome? Prenat Diagn. 2007 Apr;27(4):312–6.
14. 14. Spencer K, Spencer CE, Stamatopoulou A, Staboulidou I, Nicolaides KH. Early vaginal bleeding has no impact on markers used in first trimester aneuploidy screening. Prenat Diagn. 2010;n/a-n/a.
15. 15. Dugoff L, Faber V, Hobbins J, Malone F, Canick J, Porter F, et al. The effect of vaginal bleeding on maternal serum PAPP-A, free β-hCG, and nuchal translucency. A population based screening study (the FASTER trial). Am J Obstet Gynecol. 2004 Dec 1;191(6):S47.
16. 16. Pellizzari P, Pozzan C, Marchiori S, Zen T, Gangemi M. Assessment of uterine artery blood flow in normal first-trimester pregnancies and in those complicated by uterine bleeding: Blood flow in early pregnancy. Ultrasound Obstet Gynecol. 2002 Apr 1;19(4):366–70.
17. 17. Alcázar JL, Ruiz-Perez ML. Uteroplacental circulation in patients with first-trimester threatened abortion. Fertil Steril. 2000 Jan;73(1):130–5.
18. 18. Karslı M, Seçkin K, Cakmak B, Togrul C, Altınboğa O, Küçüközkan T. The Effect of Vaginal Bleeding on Parameters Used in the First Trimester Fetal Aneuploidy Screening Test. İstanbul Kanuni Sultan Süleyman Tıp Derg. 2015 Jun 1;7.
19. 19. Khong TY, Liddell HS, Robertson WB. Defective haemochorial placentation as a cause of miscarriage; a preliminary study. BJOG Int J Obstet Gynaecol. 1987 Jul;94(7):649–55.
20. 20. Papageorghiou AT, Yu CKH, Bindra R, Pandis G, Nicolaides KH. Multicenter screening for pre-eclampsia and fetal growth restriction by transvaginal uterine artery Doppler at 23 weeks of gestation: Doppler screening. Ultrasound Obstet Gynecol. 2001 Nov;18(5):441–9.
21. 21. Stabile I, Grudzinskas J, Campbell S. Doppler ultrasonographic evaluation of abnormal pregnancies in the first trimester. J Clin Ultrasound. 1990 Jul;18(6):497–501.
22. 22. Kurjak A, Zalud I, Predanic M, Kupesic S. Transvaginal color and pulsed Doppler study of uterine blood flow in the first and early second trimesters of pregnancy: normal versus abnormal. J Ultrasound Med. 1994 Jan;13(1):43–7.
23. 23. Kurjak A, Zudenigo D, Predanic M, Kupesic S, Funduk B. Assessment of the Fetomaternal Circulation in Threatened Abortion by Transvaginal Color Doppler. Fetal Diagn Ther. 1994;9(5):341–7.
24. 24. El Behery MM, Siam S, Seksaka MA, Mansour SM. Uterine artery Doppler and urinary hyperglycosylated HCG as predictors of threatened abortion outcome. Middle East Fertil Soc J. 2013 Mar;18(1):42–6.
25. 25. Valentin L, Sladkevicius P, Laurini R, Söderberg H, Marsal K. Uteroplacental and luteal circulation in normal first-trimester pregnancies: Doppler ultrasonographic and morphologic study. Am J Obstet Gynecol. 1996 Feb;174(2):768–75.
26. 26. Schwarze A, Nelles I, Krapp M, Friedrich M, Schmidt W, Diedrich K, et al. Doppler ultrasound of the uterine artery in the prediction of severe complications during low-risk pregnancies. Arch Gynecol Obstet. 2005 Jan;271(1):46–52.
27. 27. Jauniaux E, Van Oppenraaij RH, Burton GJ. Obstetric outcome after early placental complications: Curr Opin Obstet Gynecol. 2010 Dec;22(6):452–7.
28. 28. Tuuli MG, Norman SM, Odibo AO, Macones GA, Cahill AG. Perinatal outcomes in women with subchorionic hematoma: a systematic review and meta-analysis. Obstet Gynecol. 2011 May;117(5):1205–12.
29. 29. Weiss JL, Malone FD, Vidaver J, Ball RH, Nyberg DA, Comstock CH, et al. Threatened abortion: a risk factor for poor pregnancy outcome, a population-based screening study. Am J Obstet Gynecol. 2004 Mar;190(3):745–50.