INTRODUCTION
Pregnancy is always a significant event in a woman's life. It is often a time of hope for the future. Majority of women experience the beauty of creating and giving birth to the child. Bleeding in the very beginning of pregnancy causes emotional disruption in a woman's life. Despite the outcome of the pregnancy, bleeding during pregnancy is alarming.
Early pregnancy events and complications are among the most common complications in women during pregnancy. Most of these occur before 12 weeks of gestation and include abortion, vaginal bleeding, intrauterine hematoma, vanishing twin, and hyperemesis gravidarum. The presence of any of these complications can be extremely distressing for the women. For the clinician, it is important to interpret the symptoms and to understand the short- and long-term consequences of these complications, especially for reassuring and supporting the couple at such a difficult time.1
AIMS
To study the obstetrical complications in women with first trimester bleeding.
To evaluate the perinatal outcome in women with first trimester bleeding.
To prognosticate the obstetrical and perinatal outcome based on severity of first trimester bleeding.
To compare the obstetrical and perinatal outcome in women having normal pregnancy.
MATERIALS AND METHODS
This study was conducted in the Department of Obstetrics and Gynaecology, PBM and associated group of hospitals attached to Sardar Patel Medical College, Bikaner, India, during the study period of 1 year, i.e., January 2014 to December 2014.
Case Selection
In the study population, 100 pregnant women with gestational age up to 12 weeks irrespective of their parity with complaint of bleeding per vaginum and 100 controls attending the outpatient department in the Department of Obstetrics and Gynaecology, PBM hospital, were enrolled in the study. This is a case–control study and was performed on 100 women presenting with bleeding in first trimester and 100 controls willing to give consent for study.
Exclusion Criteria
Women who have taken medication for termination of pregnancy
Inevitable abortion, incomplete abortion
Women taking treatment for chronic diseases
Women taking chemotherapy
Ectopic pregnancy.
The approval of the hospital's ethical committee was obtained prior to the commencement of the study. Informed consent was obtained from each woman recruited in the study. The patients attending antenatal care (ANC) regularly were studied till child birth and early puerperium.
Before including patients in the study group, detailed history including age, gravida, parity, duration of marriage, last menstrual period of gestation, chief complaints, history regarding treatment for infertility/subfertility, and obstetric history were taken in each case. Gestational age was assessed by self-reported last menstrual period method and sonography.
After taking a written informed consent, patients with first trimester bleeding were admitted. Routine ANC investigations were done including ultrasonography. Duration of bleeding, amount of bleeding, and repeat episodes of bleeding were noted, and these patients were followed up and were kept under surveillance until delivery and the consequences of pregnancy were evaluated by close observation on the progress of pregnancy and prenatal and postnatal period.
Patients with threatened abortion were managed with complete bed rest till 48 hours of cessation of bleeding, folic acid supplementation, and were given tablet micronized progesterone 200 mg BD.
The women were asked to come for routine follow-up or self-referral of symptoms. Any antenatal complications like pregnancy-induced hypertension (PIH), preterm labor, premature rupture of membranes (PROM), and antepartum hemorrhage were noted.
All subjects were followed throughout the pregnancy and during labor and managed by a team of doctors who are not part of the study. Maternal outcome was assessed with respect to mode of delivery, duration of labor, and any complications in labor. After delivery, the baby was managed by neonatologist on duty who was unaware of the study and Apgar at 1 and 5 minutes was noted. Any resuscitation if required was done and any neonatal intensive care unit (NICU) care if required was provided by shifting the baby to NICU. Birth weight was recorded. Any complication developing in the baby was managed by a neonatologist.
In the newborn, sex, weight, Apgar score, gestational age and congenital anomalies, type of resuscitation if required were noted. Suggestive development of respiratory distress syndrome, intracranial or intraventricular hemorrhage, septicemia, etc., was noted. Mothers and newborn were followed till discharge from the hospital. Obstetric outcome, maternal and neonatal morbidity and mortality were recorded and analyzed using mean, standard deviation, and p value was calculated.
RESULTS
The present study was conducted in the Department of Obstetrics and Gynaecology, Sardar Patel Medical College and associated group of hospitals, Bikaner, India.
Table 1 shows that the mean period of gestation for study group was 33.17 weeks and for control group was 38.38 weeks. The difference was statistically highly significant (p < 0.001).
From Table 1 it was observed that spontaneous abortion was more in study group than in control group. Preterm deliveries were also more in study group than in control group, while term deliveries were less in study group than in control group.
The percentage of severe anemia in study group was 8% and in control group was 4%. About 19% of the patients in study group aborted, while only 4% patients aborted in control group. This difference was found statistically highly significant (p < 0.001) (Table 2).
Pregnancy-induced hypertension developed in 13.6% of patients in study group and 5.2% in control group. The percentage of intrauterine growth restriction (IUGR) in study group was 7.4% and in control group was 4.2% (Table 3).
The percentage of lower segment cesarean section in study group was 26% and in control group was 15.6%. Instrumental delivery was 1.2% in study group and there was no such case in control group. The difference was statistically highly significant (p < 0.001) (Table 4).
Table 1: Distribution of cases according to period of gestation at delivery
S: Significant; NS: Nonsignificant; SD: Standard deviation
Table 2: Distribution of cases according to obstetrical complications
| Obstetrical complications | Study group | Control group | p-value | |||
| No. | % | No. | % | |||
| Severe anemia Hb (<7 gm%) | 8 | 9.9 | 4 | 4.2 | >0.05 NS | |
| Abortion | 19 | 23.5 | 4 | 4.2 | <0.001 S | |
NS: Nonsignificant; S: Significant; Hb: Hemoglobin
Table 3: Distribution of cases according to antenatal complications
| Antenatal complications | Study group (n = 81) | Control group (n = 96) | p-value | |||
| No. | % | No. | % | |||
| PIH | 11 | 13.6 | 5 | 5.2 | <0.05 S | |
| IUGR | 6 | 7.4 | 4 | 4.2 | >0.05 NS | |
| PROM | 7 | 8.6 | 3 | 3.1 | >0.05 NS | |
| Preterm labor | 16 | 19.8 | 7 | 7.3 | <0.05 S | |
| APH | 12 | 14.8 | 4 | 4.2 | <0.05 S | |
NS: Nonsignificant; S: Significant
Table 4: Distribution of cases according to mode of delivery
| Mode of delivery | Study group | Control group | Total | |||||
| No. | % | No. | % | No. | % | |||
| Normal | 59 | 72.8 | 81 | 84.4 | 140 | 79.1 | ||
| Forceps/vacuum | 1 | 1.2 | 0 | – | 1 | 0.6 | ||
| LSCS | 21 | 26.0 | 15 | 15.6 | 36 | 20.3 | ||
| Total | 81 | 100 | 96 | 100 | 177 | 100 | ||
| p-value | <0.001 (S) | |||||||
S: Significant
Table 5: Distribution of cases according to fetal outcome
S: Significant
Table 6: Distribution of cases according to baby birth weight
S: Significant; SD: Standard deviation
The percentage of live birth with healthy outcome was 91.4% in study group and in control group was 96.9%. The percentage of still birth in study group was 4.9% and in control group it was only 1%. The percentage of early neonatal death in study group was 3.7% and in control group was 2.1%. The difference was found statistically highly significant (p < 0.001) (Table 5).
Percentage of low birth weight in study group was 18.5% and in control group was 8.3%. The percentage of very low birth weight in study group was 7.4% and in control group was 2.1%. The percentage of extremely low birth weight was 1.2% in study group and no such case was reported in control group (Table 6).
DISCUSSION
In our study, we found that early preterm delivery (20–33 weeks) was noticed in 8% cases in study group and 5% cases in control group. Late preterm delivery (34–37weeks) was also observed in 8% cases of study group while 2% cases in control group. This difference was statistically significant (p < 0.05). The percentage of patients who reached term pregnancy was 65% in study group and 89% in control group (p < 0.001). The difference was statistically significant. The mean period of gestation for study group was 33.17 weeks, and 38.38 weeks for control group.
Similar results were obtained by Yang et al2 who showed that overall association between vaginal bleeding and preterm delivery was modest. Ahmed et al3 also noticed similar results as our study in which they described that the patients with threatened abortion were associated with more preterm deliveries as compared with control group [15.7 vs 2.2%, p = 0.001].
This may be explained by the immunological reaction leading to increased free radical mediators causing oxidative stress, which may mediate the relationship between bleeding and preterm delivery. Early pregnancy bleeding may also result in infection by open access of the reproductive tract that was previously inaccessible to pathogens, which may also predispose to preterm delivery.
The percentage of PIH was more in study group as compared with control group, i.e., 13.6 and 5.2% respectively. The difference was statistically significant (p < 0.05).
Similar results were obtained by Hosseini and Yaghoubipour,4 who showed that the incidence of gestational hypertension was more in study group than in control group. In their study, difference was statistically significant (p < 0.001). The possible reason may be due to increased oxidative stress in fetomaternal circulation in patients with first trimester bleeding resulting in vasoconstriction and development of PIH.
In our study, we found that IUGR was more in study group (7.4%) as compared with control group (4.1%). The difference was statistically not significant (p > 0.05).
Our findings were similar to the study by Agrawal et al5 who stated that 6.2% cases were having IUGR in comparison to 3.8% in control group. In their study, difference was statistically nonsignificant (p > 0.98). Weiss et al6 also stated that heavy bleeding was associated with IUGR [odds ratio (OR) 2.6]. The reason for this complication is that multiple episodes of placental bleeding lead to uteroplacental insufficiency causing IUGR.
In our study, we found PROM was present in 8.6% cases in study group and 3.1% cases in control group. The difference was statistically not significant (p > 0.05).
Our findings are similar to that of the study by Agrawal et al,5 who stated that PROM was more common in patients with first trimester bleeding. The difference was statistically significant (p < 0.05). Yang et al2 also observed PROM was more common in threatened abortion.
Premature rupture of membranes may be explained as disruption of chorioamniotic plane by adjacent hemorrhage which makes the membrane more susceptible to rupture by increased free radical production within placental membrane.
In our study, antepartum hemorrhage was more in study group as compared with control group (14.8 vs 4.1%). The difference was statistically significant (p < 0.05). Similarly, Wijesiriwardana et al7 assessed that women with threatened abortion were more likely to have antepartum hemorrhage. Similar study by Agrawal et al6 stated significantly higher incidence of low-lying placenta (p =0.02). Thus, it seems that first trimester bleeding is associated with increased risk of low-lying placenta.
We found that in our study the percentage of normal vaginal delivery in cases of study group was less in comparison to control group (72.8 vs 84.4%). The percentage of cesarean section was more in study group than control group (26 vs 15.6%). Incidence of instrumental delivery was 1.2% in study group, while no case was reported in control group. The difference was statistically significant (p < 0.001).
Our findings were similar to the findings of Wijesiriwadana et al7 who assessed cesarean section was more likely in first trimester vaginal bleeding patients. Patients with first trimester bleeding are high-risk pregnancy cases having increased risk of PIH and IUGR and were more often associated with placenta previa and abruption, so patient landed up with cesarean section.
The percentage of live birth with healthy outcome was less in study group than control group (91.4 vs 96.9%). The percentage of still birth and neonatal mortality was more in study group than control group. The difference was statistically significant (p < 0.001).
Our findings were similar to that of Jauniaux et al8 who stated that risk of perinatal death was increased in study group (OR >2). Also similar findings were noticed by Nagy et al9 who observed that frequency of still birth and perinatal mortality was increased in hematoma group, but this difference was statistically not significant (p = 0.6, p = 0.2). Increased perinatal mortality may be attributed to IUGR, prematurity, respiratory distress syndrome, and birth asphyxia.
CONCLUSION
In conclusion, considering the results of our study, first trimester vaginal bleeding can be a predicting factor for adverse outcome of mother and infant. It is necessary to increase the knowledge of pregnant women in this regard for close observation. Also because the clinical intervention of attentive obstetrician has important role in not only the continuation of pregnancy but also decreasing fetal complications in these high-risk pregnancies.
Psychological support in the form of frequent discussions and sympathetic counseling can be crucial to the successful evaluation and treatment of the anxious pregnant patient. It is important that there is continued education of doctors and pregnant patients to recognize that first trimester bleeding do not always result in an undesired result.