Threatened abortion is defined as “pregnancy termination before turning 20 weeks of gestation or with a fetus born weighing less than 500gm”. It is the most common complication of pregnancy, occurring in 15-20% of ongoing pregnancy. The clinical diagnosis of threatened miscarriage is presumed when a bloody vaginal discharge or bleeding appears through a closed cervical os during the first half of pregnancy. About, 90-96% pregnancies with both fetal cardiac activity and vaginal bleeding at 7-11 weeks do not miscarry. The advent of sonography has changed the practice of obstetrics by providing a window to the womb through which anatomic structure of the fetus can be evaluated (1, 2). The addition of Doppler flow studies of maternal & fetal vessels has provided a tool where the physiology of maternal-fetal unit can be assessed (3, 4). The higher success rate is associated with bleeding at the later end of the gestational age range. In practice, once the bleeding has settled, these pregnancies are not considered high risk and do not required follow up.

Ultrasound has modified the diagnosis and the approach to the management of miscarriage. Any woman with bleeding in early pregnancy is offered ultrasound to ascertain the viability, location of the placenta and furthermore, the presence or absence of subchorionic hematoma which is associated with 4-33% rate of miscarriage. Early pregnancy bleeding is associated with adverse pregnancy outcome. Threatened abortion has associated with preterm labor and low birth weight (6), pre-eclampsia, preterm prelabour rupture of membranes (PPROM), placental abruption and intrauterine growth restriction (IUGR) (7). In this study we have examined cases of threatened miscarriage retrospectively from early in the first trimester till the ultimate outcome; we aimed to evacuate maternal and perinatal outcomes in this high risk group.

The utilization of real time scanning and improvement in image resolution following the introduction of high frequency probes have enabled accurate diagnosis and revolutionized the diagnostic as well as therapeutic management of different clinical conditions (5). The first twelve weeks of intra uterine life are the most crucial period which needs a careful eye on the growing fetus inside and if bleeding occurs at this stage history and clinical examination may frequently be inconclusive (6). Colour Doppler ultrasound plays a role of utmost importance in confirming the pregnancy, site of pregnancy, viability and also in predicting whether a pregnancy has a good chance of continuing or it is destined to fail. Colour Doppler study of ovarian blood vessels performed in early pregnancy can be helpful in predicting the risk of miscarriage and also helpful in choosing the management modality in patient with threatened abortion.

This study was carried out on 120 married women with gestational age of 5-16 week of pregnancy from Agra or nearby area, who attended Antenatal clinic or admitted in the labour room during emergency in the department of Obstetrics and Gynaecology S.N. Medical College Agra. The study was carried out during our educational period of August 2011 to Sep 2013. Approval of ethical committee of hospital was obtained at that. The patients were divided in to two groups. One was study group which include those patients who visited hospital after having signs and symptoms threatened abortion another group was control group which include those female who were having normal pregnancy without any symptom. Detail history was taken and through examination was done in all the patients, while per-speculum examination was done in patient who presented with bleeding pervaginum. Transvaginal Doppler ultrasound was done in all the patients, to see the velocimetric pattern of ovarian blood vessels. Patients with abnormal velocimetric pattern were called for follow up every weekly till next 8 weeks or till normal pattern achieved.

During this study total 120 patients underwent Doppler ultrasound of ovarian blood vessels along with obstetrical ultrasound examination at our institution. Maternal age at the time of first visit was (27.27±2.7) in study group while (26±2.6) in control group. There were no significant differences between study and control group regarding maternal age, parity, Gestational age.2 From study group mean of duration of bleeding per-vaginum was 17 hrs. The symptoms of threatened abortion such as vaginal bleeding, brownish discharge with or without cramping were detected in 17% while 29% did not have any symtoms. The “silent hematoma” in these cases was diagnosed only by ultrasound.2,3 Table 2 Present Gestational Sacpattern which includes Turgidity, Regularity of Sac, Yolk Sac. In study group 67% patients had good turgidity while in control group 83.3% patients had good turgidity. In control group 80% had regular pattern of gestational Sacwhile in study group 66.7% patient had regular pattern, Yolk sacwas found normal in 87% control group and 70% in study group.4  Table 3 Shows that 22 cases from study group aborted with mean resistivity index of (0.91± 0.01) while 38 cases continue their pregnancy with mean resistivity index of (0.78± 0.01). These are statistically significant that higher the resistivity index, higher the chances of miscarriage. All patients of abnormal velocimetric pattern were kept on progesterone support after 12 weeks of pregnancy and before this injection human chorionic gonadotropin (HCG) was given, with advice to take rest.

Table.1 Distribution of Cases According to Socio-demographic Variables

Table.2 Distribution of Cases According to Gestational Pattern

Table.3 Distribution of Cases in Study Group According to Ri of Ovarian Artery

Table.4 Comparion of Ri of Ovarian Artery in Study Group and Control Group

Bleeding in early pregnancy is a common gynecological complaint. These data showed that patients having threatened miscarriage had a significantly increased risk of complete abortion, preterm labor and low birth weight infants. Other pregnancy complications such as placenta praevia, IUGR, PIH, PROM and cesarean section rates were relatively increased, but not at significant levels. These data showed that the prediction of positive outcome in threatened abortion after confirmation of positive cardiac action on sonography was 83.1%. Similar previous evidences were reported by Goldstein et al. (1983), Batzofin et al. (1996 and 1984) and Ball RH et al. (1996) (6, 9, 10). There was no change in survival rate this constant value can be explained by the frequently offered unrewarding treatment by porgestagens and bed rest, which is supported by poor quality data. The literature reports on the association between bleeding in early pregnancy and pregnancy outcome is a conflicting one.(11,12) Many investigators reported increase incidence of preterm birth and low birth weight following threatened miscarriage In control group resistivity index mean was found (0.78± 0.01), which is in favour of good outcome of pregnancy. Due to introduction of non-invasive technology of Doppler ultrasound, it is now possible to study the flow of blood in vessels, along with other fetal parameters, In study group mean resistivity index of ovarian vessels was at higher side (0.83± 0.06). Out of 60 patients, 38 patients continue their pregnancy, while 22 cases aborted due to lack of follow up and inadequate treatment taken by the patients, In control group few cases found of having higher resistivity index of ovarian blood vessels, with abnormal velocimetric pattern and irregular fetal parameters, they were treated and prevented from future miscarriage and continue their pregnancy till term.

It is concluded that colour doppler study of ovarian blood vessels during normal asymptomatic early pregnancy seems to be useful and non invasive method of diagnosing impending abortion. It seems to be useful in the assessment of prognosis and management of threatened abortion. Resistivity index of ovarian blood vessels are utmost clinical implication to screen impending abortion and this may help us in establishing the basis to study the abnormalities in early pregnancy. But we must acknowledge the limitations of our sample size and suggest a larger study to refuse and reaffirm usefulness of colour doppler in ovarian blood vessels as a monitor in early pregnancy.

1. Burn PN. The physics of Doppler. In Chervenak FA, Isaacsar GC, Campbell S (Eds) : Ultrasound in Obstetrics and Gynaecology, Boston, Little, Brown & Co. 1993. 2. Sander Nagy, Melissa Bush, Joanne Stone, Robert H, Lipinski and Sandor Gardo. Clinical significance of subchorionic and retroplacental haematoma detected in the first trimester of pregnancy. Obst. Gynecol 2003; 102: 94-100. 3. Jouppila P. clinical consequences after ultrasonic diagnosis of intrauterine hematoma in threatened abortion. J. Clin Ultrasound, 1985; 13: 107-11. 4. Dongol A, Mool S, Timaeir P. Outcome of pregnancy complicated by threatened abortion. Kathmandu Univ Med J 2011; 33(1): 41-44. 5. Beu-Haroush A, Yogev Y, Mashiach R, Meizner I. Pregnancy outcome of threatened abortion with subchorionic hematoma possible benefit of bed rest? Isec Med Assoc. J. 2003; 5: 422-4. 6. Giobbe M, Fazzio M, Boui T. Current role of bed rest in threatened abortion. Minerva Gynecol 2001; 53: 337-40. 7. Igor Hudic, Zlatar Fatusic. Progesterone induced blocking factor (PIBF) and Th1/Th2 cytokine in women with threatened abortion. J Perinat Med 2009; 37: 338-42. 8. 1. F. gray Cunningham, Kenneth J. Leveno, Steven L. Bloom, John C. Hauth, Lary C. Gilsstrap and Katharine D. Wenstrom. William’s obstetrics 23th edition, 2010: 215-224. 9. Farrell T, Owen P. The significance of extrachorionic membrane separation in threatened miscarriage. Br J Obstet Gynecol. 1996, 103: 926-8. doi: 10.1111/j.1471 0528. 3. 10. F. gray Cunningham, Kenneth J. Leveno, Steven L. Bloom, John C. Hauth, Lary C. Gilsstrap and Katharine D. Wenstrom. Clinical diagnosis of threatened miscarriage. Williams’s obstetrics 23th edition, 2010: 215-224. 11. Tongsong T, Srisomboon J, Wanapirak C. et al. Pregnancy outcome with threatened abortion with demonstrable fetal cardiac activity: A cohort study. J obstet Gynecol (Tokyo 1995). 1995; 21: 331-5. PMID8775901. 12. Pearlstone M, Baxi L. Subchorionic haematoma: A review. Obstet Gynecol Surv. 1993; 48:65-8. PMID: 8437776. 6. Baztofin JH, Fielding WL, Friedman EA. Effect of vaginal bleeding in early pregnancy

It is concluded that colour doppler study of ovarian blood vessels during normal asymptomatic early pregnancy seems to be useful and non invasive method of diagnosing impending abortion. It seems to be useful in the assessment of prognosis and management of threatened abortion. Resistivity index of ovarian blood vessels are utmost clinical implication to screen impending abortion and this may help us in establishing the basis to study the abnormalities in early pregnancy. But we must acknowledge the limitations of our sample size and suggest a larger study to refuse and reaffirm usefulness of colour doppler in ovarian blood vessels as a monitor in early pregnancy.

1. Burn PN. The physics of Doppler. In Chervenak FA, Isaacsar GC, Campbell S (Eds) : Ultrasound in Obstetrics and Gynaecology, Boston, Little, Brown & Co. 1993. 2. Sander Nagy, Melissa Bush, Joanne Stone, Robert H, Lipinski and Sandor Gardo. Clinical significance of subchorionic and retroplacental haematoma detected in the first trimester of pregnancy. Obst. Gynecol 2003; 102: 94-100. 3. Jouppila P. clinical consequences after ultrasonic diagnosis of intrauterine hematoma in threatened abortion. J. Clin Ultrasound, 1985; 13: 107-11. 4. Dongol A, Mool S, Timaeir P. Outcome of pregnancy complicated by threatened abortion. Kathmandu Univ Med J 2011; 33(1): 41-44. 5. Beu-Haroush A, Yogev Y, Mashiach R, Meizner I. Pregnancy outcome of threatened abortion with subchorionic hematoma possible benefit of bed rest? Isec Med Assoc. J. 2003; 5: 422-4. 6. Giobbe M, Fazzio M, Boui T. Current role of bed rest in threatened abortion. Minerva Gynecol 2001; 53: 337-40. 7. Igor Hudic, Zlatar Fatusic. Progesterone induced blocking factor (PIBF) and Th1/Th2 cytokine in women with threatened abortion. J Perinat Med 2009; 37: 338-42. 8. 1. F. gray Cunningham, Kenneth J. Leveno, Steven L. Bloom, John C. Hauth, Lary C. Gilsstrap and Katharine D. Wenstrom. William’s obstetrics 23th edition, 2010: 215-224. 9. Farrell T, Owen P. The significance of extrachorionic membrane separation in threatened miscarriage. Br J Obstet Gynecol. 1996, 103: 926-8. doi: 10.1111/j.1471 0528. 3. 10. F. gray Cunningham, Kenneth J. Leveno, Steven L. Bloom, John C. Hauth, Lary C. Gilsstrap and Katharine D. Wenstrom. Clinical diagnosis of threatened miscarriage. Williams’s obstetrics 23th edition, 2010: 215-224. 11. Tongsong T, Srisomboon J, Wanapirak C. et al. Pregnancy outcome with threatened abortion with demonstrable fetal cardiac activity: A cohort study. J obstet Gynecol (Tokyo 1995). 1995; 21: 331-5. PMID8775901. 12. Pearlstone M, Baxi L. Subchorionic haematoma: A review. Obstet Gynecol Surv. 1993; 48:65-8. PMID: 8437776. 6. Baztofin JH, Fielding WL, Friedman EA. Effect of vaginal bleeding in early pregnancy

It is concluded that colour doppler study of ovarian blood vessels during normal asymptomatic early pregnancy seems to be useful and non invasive method of diagnosing impending abortion. It seems to be useful in the assessment of prognosis and management of threatened abortion. Resistivity index of ovarian blood vessels are utmost clinical implication to screen impending abortion and this may help us in establishing the basis to study the abnormalities in early pregnancy. But we must acknowledge the limitations of our sample size and suggest a larger study to refuse and reaffirm usefulness of colour doppler in ovarian blood vessels as a monitor in early pregnancy.

1. Burn PN. The physics of Doppler. In Chervenak FA, Isaacsar GC, Campbell S (Eds) : Ultrasound in Obstetrics and Gynaecology, Boston, Little, Brown & Co. 1993. 2. Sander Nagy, Melissa Bush, Joanne Stone, Robert H, Lipinski and Sandor Gardo. Clinical significance of subchorionic and retroplacental haematoma detected in the first trimester of pregnancy. Obst. Gynecol 2003; 102: 94-100. 3. Jouppila P. clinical consequences after ultrasonic diagnosis of intrauterine hematoma in threatened abortion. J. Clin Ultrasound, 1985; 13: 107-11. 4. Dongol A, Mool S, Timaeir P. Outcome of pregnancy complicated by threatened abortion. Kathmandu Univ Med J 2011; 33(1): 41-44. 5. Beu-Haroush A, Yogev Y, Mashiach R, Meizner I. Pregnancy outcome of threatened abortion with subchorionic hematoma possible benefit of bed rest? Isec Med Assoc. J. 2003; 5: 422-4. 6. Giobbe M, Fazzio M, Boui T. Current role of bed rest in threatened abortion. Minerva Gynecol 2001; 53: 337-40. 7. Igor Hudic, Zlatar Fatusic. Progesterone induced blocking factor (PIBF) and Th1/Th2 cytokine in women with threatened abortion. J Perinat Med 2009; 37: 338-42. 8. 1. F. gray Cunningham, Kenneth J. Leveno, Steven L. Bloom, John C. Hauth, Lary C. Gilsstrap and Katharine D. Wenstrom. William’s obstetrics 23th edition, 2010: 215-224. 9. Farrell T, Owen P. The significance of extrachorionic membrane separation in threatened miscarriage. Br J Obstet Gynecol. 1996, 103: 926-8. doi: 10.1111/j.1471 0528. 3. 10. F. gray Cunningham, Kenneth J. Leveno, Steven L. Bloom, John C. Hauth, Lary C. Gilsstrap and Katharine D. Wenstrom. Clinical diagnosis of threatened miscarriage. Williams’s obstetrics 23th edition, 2010: 215-224. 11. Tongsong T, Srisomboon J, Wanapirak C. et al. Pregnancy outcome with threatened abortion with demonstrable fetal cardiac activity: A cohort study. J obstet Gynecol (Tokyo 1995). 1995; 21: 331-5. PMID8775901. 12. Pearlstone M, Baxi L. Subchorionic haematoma: A review. Obstet Gynecol Surv. 1993; 48:65-8. PMID: 8437776. 6. Baztofin JH, Fielding WL, Friedman EA. Effect of vaginal bleeding in early pregnancy

It is concluded that colour doppler study of ovarian blood vessels during normal asymptomatic early pregnancy seems to be useful and non invasive method of diagnosing impending abortion. It seems to be useful in the assessment of prognosis and management of threatened abortion. Resistivity index of ovarian blood vessels are utmost clinical implication to screen impending abortion and this may help us in establishing the basis to study the abnormalities in early pregnancy. But we must acknowledge the limitations of our sample size and suggest a larger study to refuse and reaffirm usefulness of colour doppler in ovarian blood vessels as a monitor in early pregnancy.

1. Burn PN. The physics of Doppler. In Chervenak FA, Isaacsar GC, Campbell S (Eds) : Ultrasound in Obstetrics and Gynaecology, Boston, Little, Brown & Co. 1993. 2. Sander Nagy, Melissa Bush, Joanne Stone, Robert H, Lipinski and Sandor Gardo. Clinical significance of subchorionic and retroplacental haematoma detected in the first trimester of pregnancy. Obst. Gynecol 2003; 102: 94-100. 3. Jouppila P. clinical consequences after ultrasonic diagnosis of intrauterine hematoma in threatened abortion. J. Clin Ultrasound, 1985; 13: 107-11. 4. Dongol A, Mool S, Timaeir P. Outcome of pregnancy complicated by threatened abortion. Kathmandu Univ Med J 2011; 33(1): 41-44. 5. Beu-Haroush A, Yogev Y, Mashiach R, Meizner I. Pregnancy outcome of threatened abortion with subchorionic hematoma possible benefit of bed rest? Isec Med Assoc. J. 2003; 5: 422-4. 6. Giobbe M, Fazzio M, Boui T. Current role of bed rest in threatened abortion. Minerva Gynecol 2001; 53: 337-40. 7. Igor Hudic, Zlatar Fatusic. Progesterone induced blocking factor (PIBF) and Th1/Th2 cytokine in women with threatened abortion. J Perinat Med 2009; 37: 338-42. 8. 1. F. gray Cunningham, Kenneth J. Leveno, Steven L. Bloom, John C. Hauth, Lary C. Gilsstrap and Katharine D. Wenstrom. William’s obstetrics 23th edition, 2010: 215-224. 9. Farrell T, Owen P. The significance of extrachorionic membrane separation in threatened miscarriage. Br J Obstet Gynecol. 1996, 103: 926-8. doi: 10.1111/j.1471 0528. 3. 10. F. gray Cunningham, Kenneth J. Leveno, Steven L. Bloom, John C. Hauth, Lary C. Gilsstrap and Katharine D. Wenstrom. Clinical diagnosis of threatened miscarriage. Williams’s obstetrics 23th edition, 2010: 215-224. 11. Tongsong T, Srisomboon J, Wanapirak C. et al. Pregnancy outcome with threatened abortion with demonstrable fetal cardiac activity: A cohort study. J obstet Gynecol (Tokyo 1995). 1995; 21: 331-5. PMID8775901. 12. Pearlstone M, Baxi L. Subchorionic haematoma: A review. Obstet Gynecol Surv. 1993; 48:65-8. PMID: 8437776. 6. Baztofin JH, Fielding WL, Friedman EA. Effect of vaginal bleeding in early pregnancy