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Am Fam Physician. 2005;72(8):1604

As many as 25 percent of women who are pregnant experience vaginal bleeding during the first trimester. Approximately one half of these women progress to miscarriage. Early identification of the nonviable pregnancies through ultrasonography provides more time for decisions about expectant management or intervention. Conversely, confirming viability can offer patients reassurance. Schauberger and colleagues studied the contribution of ultrasonography to the management of first-trimester bleeding.

The researchers studied all pregnant women admitted to a regional medical center between 1998 and 2000 with first-trimester bleeding. Of the 715 women who underwent ultrasound examination, 314 were assessed as having viable pregnancies, 236 had non-viable pregnancies, and 39 had ectopic pregnancies. No pregnancy was identified in the remaining 126 women. In the group deemed viable by ultrasonography, pregnancy continued to the end of the first trimester in 270 women (86 percent). Spontaneous abortion occurred in 16 patients (5 percent) and five (2 percent) required emergency evacuation because of severe bleeding. The remaining 23 patients (7 percent) underwent scheduled evacuation. In the 236 women with nonviable pregnancies on ultrasound, 96 (41 percent) opted for expectant management. Spontaneous abortion occurred within a week in 70 percent of these patients. The final diagnoses for the group with no intrauterine pregnancy were: (1) complete spontaneous abortion (80 percent); (2) ectopic pregnancy (17 percent); and (3) viable pregnancies (2 percent). In the entire group of 715 women studied, the only complication was one mild case of postabortion endometritis.

If ultrasonography reported a nonviable pregnancy, expectant management was significantly less expensive than scheduled curettage ($652 compared with $1,966). Spontaneous abortion ($878) also was significantly less expensive than scheduled or emergency evacuation ($2,473 and $6,208, respectively) for women who eventually miscarried after initial ultrasonography revealed a viable pregnancy.

The authors conclude that ultrasonographic demonstration of fetal heartbeat is highly predictive of viability in the first trimester, even if vaginal bleeding occurs, because approximately 86 percent of these pregnancies continue. They emphasize that expectant management was successful in 74 percent of nonviable pregnancies and that 70 percent resolved in miscarriage within one week. Overall, ultrasonography provided physicians and patients with crucial information to use in management decisions.

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