Objective: Bleeding during the first trimester of pregnancy is common and can be a sign of complication that often necessitates obstetric ultrasound for the assessment of the haemorrhage, and of fetal well being. The aim of this study was to determine the causes of first trimester bleeding on obstetrical ultrasound in our area. Method: It was a cross-sectional descriptive study during a six-month period from May to October 2017. All women who referred to the Regional center of medical imaging of Ngaoundere who agreed to participate in the study with first trimester bleeding were evaluated with clinical history and ultrasonography (US). Ultrasonographic exam was done via transabdominal or endovaginal approaches using GE LOGIQ 7 scanner brand. Microsoft Office Excel 2010 and SPHINX V 4.0 were used for data analysis. Results: A total of 121 of pregnant women who presented vaginal bleeding during the first trimester were enrolled into the study. These Ultrasound examinations represented 37.93% of all obstetric ultrasounds in the first trimester. The patients in this study ranged in age from 16 to 47 years with an average of 30 years. 50 (41.32%) were pregnant for the first time and 24 (19.83%) were primiparous. Mean gestational age was 9 weeks with the extremes of 5 and 12 weeks. 97 (80.2%) reported spontaneous bleeding while in 24 (18.8%) bleeding was mostly caused by sexual intercourse 11 (45.8%). Pelvic pain 91 (75.2%) was the most associated sign. 36 (29.8%) patients were diagnosed as threatened abortions. 27 (22.3%) were diagnosed with incomplete abortions. 4 (3.3%) cases showed an ectopic gestation. 9 (7.4%) cases showed complete abortions. Concordance between clinical diagnosis and ultrasound results was 84%. Conclusions: Bleeding in the first trimester of pregnancy is common in our area. Ultrasonography occupies a prominent place in the etiological diagnosis of bleeding in the first trimester of pregnancy; it is easy to find in most cases a responsible abnormality of bleeding.
First trimester bleeding is common in the emergencies and occurs to pregnant women who are 12 weeks or less of amenorrhea [
We carried out a descriptive cross-sectional study. It took place at the Regional Center for Medical Imaging of Ngaoundere Regional Hospital from May to October 2017. This study included all patients up to 12 weeks of gestational age who agreed to participate in the study with first trimester bleeding referred to the center for ultrasonography examination. All patients with non-obstetrical causes of vaginal bleeding and whose records were not complete were excluded. Sampling was consecutive and exhaustive non probabilistic. Data was collected from the radiologist report and request forms of patients. All the patients were scanned using GE LOGIQ 7 Ultrasound. These studies was done using either a 3.5 MHz probe trans abdominal. Transvaginal ultrasonography was performed when the patient’s bladder was empty and when the gestational week was 7 weeks or less, using 4.2 - 6.5 MHz endocavitory probe. The variables studied were age, profession, gravidity, parity, heaviness of bleeding, ultrasound results and concordance rate between clinical diagnosis and ultrasound diagnosis. To determine the amount of bleeding, it is based on the condition of the sanitary napkins during the duration of bleeding, if we observe that a point on the towel, we speak of spotting, if the towel partially soaked, the bleeding is light, if the towel is completely soaked with debortment and blood clots one speaks of heavy bleeding. The concordance rate was calculated as the ratio of the number of ultrasound diagnosis to the number of clinical diagnosis multiplied by one hundred. During ultrasound examination, the following findings was noted like uterine size, presence and location of the gestational sac, crown rump length (CRL), cardiac activity, foetal movements, presence or absence of foetal pole an finally a study of adnexa and presence of any free fluid in the cul-de-sac. All the data collected were analyzed using Microsoft Excel 2010 and Sphinx version 4.0 to produce frequency tables and charts. There was cross tabulations to explore relationship between variables. Ethical approval was obtained from the ethical Committee of Ngaoundere Regional Hospital
One hundred and twenty one (121) women aged between 16 and 47 years old with an average of 30 years were enrolled in this study. The modal age group was 30 to 34 years old representing 31.4% (
There was a statistically significant relation (p = 0.001) between ultrasonography findings and the heaviness of bleeding (
Age group | Frequency | Percentage (%) |
---|---|---|
≤25 y | 9 | 7.4 |
26 - 29 y | 33 | 27.3 |
30 - 34 y | 38 | 31.4 |
35 - 39 y | 20 | 16.5 |
40 - 44 y | 18 | 14.9 |
≥45 y | 3 | 2.5 |
Total | 121 | 100 |
Profession | Frequency | Percentage (%) |
---|---|---|
Housewife | 54 | 44.6 |
Student | 22 | 18.1 |
Dressmaker | 12 | 9.9 |
Teacher | 10 | 8.3 |
Tradeswoman | 6 | 5 |
Nurse | 4 | 3.3 |
Secretary | 3 | 2.5 |
Farmer | 2 | 1.7 |
Other* | 8 | 6.6 |
TOTAL | 121 | 100 |
*Other = cashier, hairdresser, accountant, journalist, veterinary.
Frequency | Percentage (%) | |
---|---|---|
Gestational age | ||
- ≤6 weeks | 12 | 11.4 |
- 6 to 10 weeks | 79 | 75.2 |
- 10 to 12 weeks | 14 | 13.3 |
Gravidity | ||
- Primigravida | 50 | 41.32 |
- Multigravida | 71 | 58.67 |
Parity | ||
- Primipara | 24 | 19.83 |
- Multipara | 53 | 43.8 |
Frequency | Percentage (%) | |
---|---|---|
Bleeding | ||
- Spontaneous | 97 | 80.2 |
- Caused | 24 | 18.8 |
Heaviness of bleeding | ||
- Spotting | 54 | 44.6 |
- Light | 34 | 28.1 |
- Heavy | 33 | 27.3 |
Circumstances of occurrence | ||
- Sexual intercourse | 11 | 9.9 |
- Physical effort | 3 | 2.47 |
- Other* | 10 | 8.26 |
*Other = road accident, personal hygiene.
USG Diagnosis | Gupta N et al. [ | Aronu et al. [ | Priso B et al. [ | Present study |
---|---|---|---|---|
Threatened abortions | 72 (36%) | 66 (65.3%) | 73 (27.2%) | 36 (29.8%) |
Incomplete abortions | 40 (20%) | 7 (6.9%) | 26 (9.7%) | 27 (22.3%) |
Stopped pregnancy | - | - | 55 (20.5%) | 22 (18.2%) |
Normal pregnancy | - | - | 14 (5.2%) | 19 (15.7%) |
Complete abortions | 24 (12%) | 9 (8.9%) | 12 (4.5%) | 9 (7.4%) |
Ectopic gestation | 16 (8%) | 3 (3%) | 1 (0.4%) | 4 (3.3% |
Anembryonic gestation | 8 (4%) | 1 (1%) | 33 (12.3%) | 3 (2.5%) |
Molar pregnancy | 8 (4%) | 3 (3%) | 7 (2.6%) | 1 (0.8%) |
Bleeding | ||||
---|---|---|---|---|
USG findings | Heavy | light | Spotting | Total |
Threatened abortions | 4 | 9 | 23 | 36 |
Incomplete abortions | 17 | 7 | 3 | 27 |
Stopped pregnancy | 3 | 12 | 7 | 22 |
Normal pregnancy | 1 | 3 | 15 | 19 |
Complete abortions | 6 | 1 | 2 | 9 |
Ectopic gestation | 1 | 1 | 2 | 4 |
Anembryonic Gestation | 1 | 1 | 1 | 3 |
Molar pregnancy | 0 | 0 | 1 | 1 |
TOTAL | 33 | 34 | 54 | 121 |
Blood clots | Retained products of conception | |||
---|---|---|---|---|
USC results | Yes | No | Yes | No |
Threatened abortions | 13 | 23 | 3 | 33 |
Incomplete abortions | 22 | 5 | 2 | 25 |
Stopped pregnancy | 11 | 11 | 4 | 18 |
Normal pregnancy | 4 | 15 | 1 | 18 |
Complete abortions | 6 | 3 | 2 | 7 |
Ectopic gestation | 3 | 1 | 0 | 4 |
Anembryonic Gestation | 1 | 2 | 1 | 2 |
Molar pregnancy | 0 | 1 | 0 | 1 |
Total | 60 | 61 | 13 | 108 |
patients with incomplete abortions had blood clots during bleeding. Therefore there is no statistically significant relation between ultrasound results and the existence of retained products of conception (P = 0.056). The confrontation between the clinical diagnosis and the ultrasound results showed a concordance rate of 84% (
A total of 121 of pregnant women who presented vaginal bleeding during the first trimester referred to the center for an ultrasonography examination were enrolled into the study. These ultrasound examinations represented 37.93% of all obstetric ultrasounds in the first trimester, so this is a common pattern of ultrasound. The 121 women in this study ranged in age from 16 to 47 years with an average of 30 years. The target for these disturbances is logically made up of women of childbearing age. Patients aged between 30 and 34 years (31.4%) were more represented. This rate is in accordance with findings reported in similar studies [
In our study, 97 (80.2%) women reported spontaneous bleeding while 24 (18.8%) bleeding were caused, mostly by sexual intercoursies 11 (45.8%). Indeed this period of pregnancy is delicate and the bleeding can occur even if the trauma is minimal.
The heaviness of bleeding occurring during first trimester pregnancies varies according to the etiology (p = 0.001). Patients with incomplete abortions had such heavy bleeding as those with complete abortions. It is important to estimate the heaviness of bleeding and to look for associated signs in order to assess the
Category | Clinical diagnosis | USG diagnosis | Normal USG |
---|---|---|---|
Threatened abortions | 46 | 36 | 9 |
Incomplete abortions | 35 | 27 | 5 |
Stopped pregnancy | 26 | 22 | 3 |
Complete abortions | 13 | 9 | 2 |
Ectopic gestation | 1 | 4 | 0 |
Anembryonic Gestation | 0 | 3 | 0 |
Molar pregnancy | 0 | 1 | 0 |
Total | 121 (100%) | 102 (84%) | 19 (16%) |
patient’s hemodynamic status and evoking the etiology. The most common associated sign in our series is pain as and in the literature [
As ultrasonography findings, threatened abortion (29.8%) was the commonest cause of first trimester vaginal bleeding. This similar trend was observed in other studies [
27 (22.3%) women were diagnosed with incomplete abortions. This rate is comparable to that of Yang and al, who found a rate of 23.1% [
There were 22 (18%) cases of stopped pregnancies (fetal demise). Belley Priso and al found a rate of 20%. As US features, there was an ovular gestational sac containing an embryo with no cardiac activity detected [
Bleeding from an ectopic pregnancy is the most dangerous cause of first trimester bleeding. It concerned 3.3% of the cases in our study. Belley and al found a rate of 5.2%. It occurs when the fertilized egg is implanted outside of the uterus, most often in the Fallopian tube. The ultrasonographic finding was the visualization of an annular adnexal mass containing a viable embryo or not (
9 (7.4%) were diagnosed as complete abortion. This rate is similar to those of Coulibaly who found a rate of 9.1% [
An anembryonic pregnancy (blighted ovum) is an early failure of the embryo to develop within the GS. 3 (2.5%) patients were diagnosed with blighted ovum. Diarisso in 2011 found a rate of 4.3% [
Molar pregnancy is the most common gestational trophoblastic disease. It results from the fecundation of a single egg with no active nucleus, which means all the chromosomes present in the hydatidiform mole are paternal [
Correct management of cases depends on correct diagnosis. In our study
concordance between clinical diagnosis and ultrasonographic diagnosis was 84%. 3 (2.5%) cases of anembryonic gestation and 1 (0.8%) case of molar pregnancy were diagnosed based on USG, none of them were diagnosed clinically. This concordance rate in our study is relatively high, but low compared to most studies where the concordance rate varies from 96% to 100% [
Nonspecific sonographic findings in a patient with first trimester bleeding should be correlated with serum beta hCG levels to arrive at an appropriate clinical diagnosis, what is not the case in our study and what makes the diagnosis often difficult. Limitations of this study also include the difficulty to assess the outcome of pregnancies, most of the patients did not come back to attend their prenatal follow-up.
Bleeding in the first trimester pregnancies is a very common obstetrical problem, indeed is a frequent cause for assessing ultrasound scans at the regional hospital of Ngaoundere. It is a source of anxiety both to the patients and the obstetrician. This study shows that it is the common problem in 26 - 34 age pregnant women. The most common causes of first trimester bleeding are threatened abortions, incomplete abortions, stopped pregnancies, complete abortions, ectopic gestation, anembryonic gestation and molar pregnancy. 15.7% of pregnancies with first trimester bleeding are normal. Our study has shown the low concordance between clinical diagnosis and ultrasonographic diagnosis compared to other studies. This highlights the need for availability of ultrasound devices and trained sonographers to guide the clinician for better management of cases.
The authors declare that there is no conflict of interests regarding the publication of this paper.
Neossi Guena, M., Zilbinkai Alapha, F., Maleu Kemegne, D.C., Nkigoum Nana, A., Zeh, O.F. and Gonsu Fotsing, J. (2019) Ultrasound Study of First Trimester Bleeding. Open Journal of Radiology, 9, 58-68. https://doi.org/10.4236/ojrad.2019.91006