http://www.ijwhr.net doi 10.15296/ijwhr.2016.

02

Open Access Original Article

International Journal of Women’s Health and Reproduction Sciences
Vol. 4, No. 1, January 2016, 4-7
ISSN 2330- 4456

First Trimester Bleeding and Pregnancy Outcomes: Case-

Control Study
Betül Yakıştıran, Tuncay Yüce*, Feride Söylemez

Abstract
Objectives: The purpose of this study was to determine the perinatal outcome and pregnancy complication (preterm delivery,
preterm prelabour rupture of membrane [PPROM], preeclampsia, placental abruption and intrauterine growth restriction [IUGR])
of threatened miscarriage.
Materials and Methods: A total of 963 patients attended the study. Of these, 493 women had threatened miscarriage. The control
group included 470 pregnants without first trimester vaginal bleeding. We compared the two groups according to maternal age,
gravida, parity, spontaneous or induced abortion history, pregnancy period, livebirth or pregnancy loss, newborn weight and Apgar
values after 1 and 5 minutes, newborns’ gender for livebirth and preterm deliveries.
Results: Incidence of preterm delivery, abortion, lower gestational fetal weight and preterm rupture of membrane was increased in
threatened miscarriage group. Mean pregnancy period in threatened miscarriage group was 243 days; in control group was 263 days.
There was adverse influence of maternal age and abortion history on outcomes in pregnancies with threatened miscarriage. However
sex of the fetuses and Apgar values after 1 and 5 minutes were similar between two groups.
Conclusion: Threatened miscarriage is an important situation to predict both the maternal and fetal outcomes in late pregnancy.
Maternal obstetric history on previous pregnancies should be questioned. It is therefore essential to consider these pregnancies as
high risk group and provide careful antenatal care.
Keywords: Abortion, Uterine hemorrhage, Perinatal outcomes, Preterm labor

Introduction increase the risk of abortus imminens.

First trimester bleeding is a common symptom of preg- The purpose of this study was to investigate whether
nancy, complicating 16%-25% of all pregnancies (1-3). threatened abortion makes pregnancies high risk, what
The four major sources of nontraumatic bleeding in ear- is poor neonatal outcome and which maternal character-
ly pregnancy are ectopic pregnancy, miscarriage (threat- istics change these results in our clinic. Answer to these
ened, inevitable, incomplete or complete), implantation questions can change our antepartum, peripartum and
of pregnancy and cervical pathology. Physical and pelvic postpartum management. We aimed to investigate threat-
examination should be done and further with the help of ened abortion and pregnancy outcomes in our patients.
imaging techniques, diagnosis and plan of management
is planned. Materials and Methods
Abortus imminens is diagnosed as first trimester vaginal In this retrospective study we examined 493 patients with
bleeding with closed cervix and confirmed with fetal heart diagnosis of abortus imminens who were admitted to the
rate on ultrasound (3,4). Doppler confirmation of fetal Department of Gynecology and Obstetric, Medical Fac-
cardiac activity is reassuring as it indicates that bleeding ulty, Ankara University between 2007 and 2015. Threat-
is not related to fetal demise. After determining the diag- ened miscarriage was defined as positive fetal heart rate
nosis, management is important. Nearly 50% of pregnan- on ultrasound and a history of vaginal bleeding in the first
cies end in pregnancy loss; if pregnancy continues, poor trimester. We examined 470 singleton pregnant women
maternal and fetal outcomes such as preterm delivery (4), as control group with no symptoms of threatened miscar-
preterm prelabour rupture of membrane (PPROM), pre- riage such as vaginal bleeding, spotting or pelvic pain.
eclampsia, placental abruption and intrauterine growth 493 women with threatened miscarriage were considered
restriction (IUGR) may occur (1,3,5). It is known also that as group A. Control group (group B) included 470 preg-
maternal age (5,6), systemic diseases such as diabetes mel- nants without first trimester vaginal bleeding. We com-
litus, hypothyroidism, infertility treatment (1), thrombo- pared the two groups according to maternal age, gravidity,
philia, maternal weight and uterine structural anomalies parity, spontaneous or induced abortion history, pregnan-

Received 6 February 2015, Accepted 1 October 2015, Available online 1 January 2016

Department of Obstetric and Gynecology, Ankara University, Ankara, Turkey.

*Corresponding author: Tuncay Yüce, Faculty of Medicine, Ankara University, Cebeci Campus, Mamak/Ankara, Turkey. Tel: +903125956405,
Email: drtuncayyuce@gmail.com
Yakıştıran et al

cy period, livebirth or pregnancy loss, newborn weight

and Apgar scores after 1 and 5 minutes, newborns’ gender (88.3%) from group A, pregnancies continued after 24
for livebirth and preterm deliveries. weeks’ of gestation. The relationship between vaginal
Outcome measures included preterm labour, fetal birth bleeding and preterm delivery subtypes was also eval-
weight, Apgar scores after 1 and 5 minutes, livebirth or uated. In this study population 94 patients (21.6%) of
pregnancy loss, sex of the fetuses, and previous maternal preterm cases delivered between 24-37 weeks’ gestation.
obstetric history (gravidity, parity, spontaneous abortion, In preterm deliveries; 60 patients (63.8%) delivered be-
induced abortion history). The assessment of all patients tween 34-37 weeks’ gestation; 21 patients (22.3%) between
included maternal disease; hereditary thrombophilia, 28-34 weeks’ gestation and 13 patients (13.8%) between
chronic hypertension and diabetes mellitus, hypothy- 24-28 weeks’ gestation.
roidism, preeclampsia and fetal abnormality. Hereditary In group A; hereditary thrombophilia was found in 20
thrombophilia included thrombosis, G1691A mutation in patients during pre-pregnancy assessment. These patients
the factor 5 gene, G20210A mutation in the prothrombin had used low molecular weight heparin during whole
gene, C677T mutation and A1298C mutation in MTHFR pregnancy period. Twenty-nine patients were hypothy-
gene, antithrombin 3, protein C and S deficiency. roid, 4 of them complicated with placenta previa and preg-
The inclusion criteria were singleton pregnancies com- nancy induced hypertension occurred in two patients. 11
plicated with vaginal bleeding at less than 14 weeks’ ges- of them had different diseases such as asthma (one pa-
tation with positive fetal heart pulsations detected with tient), psychosis (3 patients), cervical cancer (1 patient),
ultrasound. The gestational age was estimated from last cardiac surgery (2 patients), chronic hypertension (3 pa-
menstrual period and the first trimester ultrasound. If the tients), pregestational diabetes mellitus (2 patients), and
self reported last menstrual period was >7 days from the sarcoidosis (1 patient). Also 29 patients of group A were
calculated ultrasound last menstrual period; then the ul- hypothyroid and 5 of them had spontaneous abortion.
trasound was used to assign the gestational age. Women in the threatened miscarriage group; 10 of them
Multiple pregnancies, patient who had gynecological pa- had complication with placenta previa; 5 of them com-
thologies such as polyps, cervicitis or cervical myomas plicated with preeclampsia. And 13 of these patients had
were excluded. All patients’ pregnancy period were re- pregnancy induced hypertension during the pregnancy.
corded and preterm delivery ( <37 weeks’ gestation) and Only one of them had intrauterine exitus and fetus was
abortion (<24 weeks’ gestation) were accepted. terminated after that. Also cholestasis was observed in
Data were analysed with SPSS.21.0. The statistical analysis three patients. In early gestational weeks 5 major fetal ab-
of the differences between the patient and control groups normalities were determined with ultrasound scan. Three
for the parameters showing normal distribution was done of them were trisomy 21 and all were terminated. The
with a parametric test “independent-samples Student’s t other abnormalities included Walker-Warburg syndrome
test.” Used as a non-parametric test, the “Mann-Whitney and cystic hygroma; these pregnancies did not terminate
U” was used to make comparisons among the parame- because of absence of parental consent. Only one placen-
ters that did not demonstrate normal distribution. Pear- tal abruption occurred in 33 weeks’ gestation. IUGR in 9
son chi-square tests (non-parametric) were performed to pregnancies and gestational diabetes mellitus in 13 pa-
test statistical significance of the differences in propor- tients were diagnosed.
tions. A value of P < 0.05 was considered to be statistically As seen below, in group A with threatened abortion, ma-
significant. ternal age was higher than control group and statistical-
ly significant. There were no differences in gravidity be-
Results tween two groups. However, there were statistically differ-
We examined the patients with threatened miscarriage ences in parity and spontaneous abortion rates. In control
diagnosis who applied to the clinic because of the first tri- group, pregnancy period is more longer than group A
mester vaginal bleeding between 2007 and 2015. A total expectedly. Gender of fetuses were similar in both groups.
of 963 patients attended the study. Of these, 493 women Because of the higher rates of preterm delivery in group
had threatened miscarriage (group A). The control group A; birth weight was lower in this group when compared
(group B) included 470 pregnants without first trimester with control group. However interestingly APGAR scores
vaginal bleeding. Results for the two groups are presented in first and 5 minutes did not change.
on Table 1. In group A cervical cerclage was performed in only one
In group A there were two groups; the first was with patient who had history of cervical conization. In eight pa-
livebirth and the second was spontaneous abortion. Both tients preterm premature rupture of membrane occurred.
of these groups were compared with each other in regard In group A, there were two groups; livebirth and spon-
to maternal age, gravidity, parity, spontaneous or induced taneous abortion groups. When we compared these two
abortion history. However there were not statistically sig- groups maternal age, gravidity, parity, presence of sponta-
nificant differences among groups. neous or induced abortion before and livebirth had sim-
In 58 patients (11.7%) from group A, terminated their ilar rates. In threatened abortion group, there was no sta-
pregnancies with spontaneous abortion. In 435 patients tistically significance between abortion or livebirth during
pregnancy (Table 2).

International Journal of Women’s Health and Reproduction Sciences, Vol. 4, No. 1, January 2016 5
Yakıştıran et al

Table 1. Comparison of Outcomes of Pregnancies in Control and ond trimester bleeding were similar (4,10).
Case Groups Preterm delivery and PPROM rates were increased in
Threatened Control the threatened miscarriage group (4,7,9,11,12). Because
Aborton (n = 493) P Valuea
Maternal age 33.5±5.4 (n = 470) of increased free iron deposits from subchorionic bleed-
28.8±5.2 <0.001 ing, hydroxyl radical is catalyzed damaging the mem-
Gravida 2.1±1.2 1.9±1.1 0.077
branes (4,7). The other point in PPROM’s etiology is the
Parity 0.51±0.75 0.68±0.94 0.006 chronic inflammatory reaction within the decidua and
Spontanous aborton 0.51±0.86 0.18±0.5 <0.001 placental membranes with weakening and rupture of the
Dilataton curetage 0.14±0.47 0.09±0.42 0.11 membranes. Investigators have speculated that decidual
Livebirth 0.46±0.71 0.65±0.78 0.002 thrombosis, ischemia and necrosis result in vaginal bleed-
Pregnancy period 243±59 263±35 <0.0001 ing along with inflammatory response and thrombin for-
mation. Thrombin is a uterotonic agent and may cause
Birth weight 3115±665 3239±619 0.005
preterm labor during late pregnancies and spontaneous
Gender (f/m) 180/206 188/262 0.147
abortion during early weeks of gestation (3,9,13,14). Sub-
Apgar 1 min 8±(0-9) 8±(0-9) 0.080 chorionic hematoma can result in a nidus which may be-
(median ± min-max)
come infected and cause preterm rupture of membranes
Apgar 5 min 9±(0-10) 9(0-10) 0.060
(13). In Saraswat et al study similar results were demon-
(median ± min-max)
strated for PPROM (3).
Preterm delivery 94/493 40/470 <0.001
Both preterm delivery and PPROM are related with low
Abortus 58/493 a
20/470 <0.001
birth weight as predictable factors. Our study demon-
P < 0.05 is significant.
strated that the fetal weight was lower in the case than
control group. It is related with births at earlier gestations
Table 2. Spontaneous Abortion and Livebirth Groups in Group A (7,15). Neonatal intensive care unit admission for low
Livebirth Aborton birth weight fetuses was increased because of prematu-
(n = 435) (n = 58) P Value rity complications such as respiratory distress (7). The
Age 33.3±5.3 34.8±6.1 0.11 objective parameter of fetal outcome cord blood sample
Gravida 2.1±1.2 2.1±1.4 0.21 was not detected for fetal pH. But we recorded APGAR
Parity 0.50±0.75 0.55±0.94 0.25 scores after one and five minutes. In our study interesting-
ly, we did not find relationship between the control group
Aborton history 0.51±0.86 0.44±0.78 0.55
and threatened miscarriage group for Apgar scores. As an
Dilataton curetage history 0.13±0.46 0.24±0.51 0.075 opinion, lower Apgar scores after 1 and 5 minutes were ex-
Livebirth 0.46±0.70 0,48±0.78 0.61 pected in threatened abortion group because of increased
a rates of preterm delivery.
P < 0.05 is significant.
Additionally in threatened miscarriage group, maternal
obstetric history (gravidity, parity and spontaneous or
Discussion induced abortion, intrauterine exitus) was important for
This study indicates that women who have vaginal bleed- examinations during prenatal care. With previous threat-
ing in the first trimester are at increased risks of later ened miscarriages, this pregnancy may be more compli-
pregnancy complications; especially preterm delivery, cated with preterm delivery, PPROM, lower birth weight
shortened mean pregnancy period, lower gestational fetal (1,2,4,9,13). In literature also this situation was related
weight and preterm rupture of membrane (1,2,7). Mean with pregnancy induced hypertension and preeclampsia
pregnancy period in threatened miscarriage group was and lower Apgar scores with poor previous obstetric his-
243 days; in control group it was 263 days. There was ad- tory (5).
verse influence of maternal age and abortion history on Bleeding amount and characteristics are related with poor
outcomes in pregnancies with threatened miscarriage maternal and fetal outcome (7,10,12,14) which was we did
(6,8). However sex of the fetuses and Apgar scores after 1 not record. Our study was retrospective so that we inves-
and 5 minutes were similar between two groups. tigated only patient records. If subchorionic hematoma
Bleeding during first trimester was associated with in- had occurred, we recorded the size of the hematoma in
creased risk of preterm delivery (4). Because of impaired the ultrasound scanning forms. Our sample size for hema-
implantation and invasive trophoblasts, spontaneous toma wasn’t enough so we did not include it. All patients
abortion may occur in early pregnancy while preterm de- data were obtained from computer database and patients’
livery, PPROM, placental ablation and preeclampsia may files so that number of patients are under estimated. In
happen in later period (2,4,9). Our results were similar our clinic, very few patients who were complicated with
to those reported before by Hossain et al (4). According threatened abortion were hospitalized; so very few pa-
to these studies, the first and second trimester bleeding tients were included in this investigation. We included
complications are more likely than only the first trimester only those patients that had full data both n computer da-
bleeding. But only risk of preterm delivery in first or sec- tabase and patients files.

6 International Journal of Women’s Health and Reproduction Sciences, Vol. 4, No. 1, January 2016
Yakıştıran et al

Conclusion A, Liversedge N, Taylor M. The influence of

In conclusion threatened miscarriage is an important situ- maternal age on the outcomes of pregancies
ation to predict late pregnancy results; both maternal and complicated by bleeding at less then 12 weeks. Acta
fetal outcomes. Maternal obstetric history about previous Obstetricia et Gynecologica 2009;88(1):116-118.
pregnancies should be questioned. It is therefore accept- doi:10.1080/00016340802621005.
able to consider these pregnancies as high risk group for 7. Johns J, Jauniaux E. Threatened miscarriage
which antenatal care should be performed carefully. as a predictor of obstetric outcome. Obstet
Gynecol. 2006;107:845-850. doi:10.1097/01.
Ethical issues AOG.0000206186.91335.9a.
An inquiry was made and sent to Ankara University 8. Yang J, Savitz DA, Dole N, et al. Predictors of vaginal
Ethics Commission. Due to nature of non-confidential bleeding during the first two trimesters of pregnancy.
data required for study, retrospective nature of data col- Paediatric Perinatal Epidemiol. 2005;19(4):276-283.
lection, ethics approval and patient consent was deemed doi: 10.1111/j.1365-3016.2005.00655.x.
unnecessary. 9. Hackney DN, Glantz JC. Vaginal bleeding in early
pregnancy and preterm birth: systematic review and
Conflict of interests analysis of heterogeneity. J Maternal-Fetal Neonatal
None to be declared. Med. 2011;24(6):778-86. doi:10.3109/14767058.2010
.530707.
Financial support 10. Velez Edwards DR, Baird DD, Hasan R, Savitz DA,
Our study did not use funds from any authority. Hartmann KE. First trimester bleeding characteristics
associate with increased risk of preterm birth: data
Acknowledgments from a prospective pregnancy cohort. Hum Reprod.
None to be declared. 2012;27(1):54-60. doi:10.1093/humrep/der354.
11. Yang J, Savitz DA. The effect of vaginal bleeding
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International Journal of Women’s Health and Reproduction Sciences, Vol. 4, No. 1, January 2016 7