Abstract
Both ultrasound and biochemical markers either alone or in combination have been described
in the literature for the prediction of miscarriage. We performed this systematic
review and meta-analysis to determine the best combination of biochemical, ultrasound
and demographic markers to predict miscarriage in women with viable intrauterine pregnancy.
The electronic database search included Medline (1946–June 2017), Embase (1980–June
2017), CINAHL (1981–June 2017) and Cochrane library. Key MESH and Boolean terms were
used for the search. Data extraction and collection was performed based on the eligibility
criteria by two authors independently. Quality assessment of the individual studies
was done using QUADAS 2 (Quality Assessment for Diagnostic Accuracy Studies-2: A Revised
Tool) and statistical analysis performed using the Cochrane systematic review manager
5.3 and STATA vs.13.0. Due to the diversity of the combinations used for prediction
in the included papers it was not possible to perform a meta-analysis on combination
markers. Therefore, we proceeded to perform a meta-analysis on ultrasound markers
alone to determine the best marker that can help to improve the diagnostic accuracy
of predicting miscarriage in women with viable intrauterine pregnancy. The systematic
review identified 18 eligible studies for the quantitative meta-analysis with a total
of 5584 women. Among the ultrasound scan markers, fetal bradycardia (n = 10 studies, n = 1762 women) on hierarchical summary receiver operating characteristic showed sensitivity
of 68.41%, specificity of 97.84%, positive likelihood ratio of 31.73 (indicating a
large effect on increasing the probability of predicting miscarriage) and negative
likelihood ratio of 0.32. In studies for women with threatened miscarriage (n = 5 studies, n = 771 women) fetal bradycardia showed further increase in sensitivity (84.18%) for miscarriage
prediction. Although there is gestational age dependent variation in the fetal heart
rate, a plot of fetal heart rate cut off level versus log diagnostic odds ratio showed
that at ≤110 beat per minutes the diagnostic power to predict miscarriage is higher.
Other markers of intra uterine hematoma, crown rump length and yolk sac had significantly
decreased predictive value. Therefore in women with threatened miscarriage and presence
of fetal bradycardia on ultrasound scan, there is a role for offering repeat ultrasound
scan in a week to ten days interval.
Keywords
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References
- Spontaneous fetal loss after demonstration of a live fetus in the first trimester.Obstet Gynecol. 1987; 70: 827-830
- Rate of spontaneous abortion after first trimester sonographic demonstration of fetal cardiac activity.Am J Perinatol. 1988 Jan; 5: 1-4
- Yolk sac size and embryonic heart rate as prognostic factors of first trimester pregnancy outcome.Eur J Obstet Gynecol Reprod Biol. 2008; 138: 10-13
- A prediction model for viability at the end of the first trimester after a single early pregnancy evaluation.Aust N Z J Obstet Gynaecol. 2013; 53: 51-57
- QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies.Ann Intern Med. 2011; 155: 529-536
- A unification of models for meta-analysis of diagnostic accuracy studies.Biostatistics. 2007 Apr; 8: 239-251
- A hierarchical regression approach to meta-analysis of diagnostic test accuracy evaluations.Stat Med. 2001; 20: 2865-2884
- Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.Ann Intern Med. 2009; 151: 264-269
- Heart rate as a predictor of first-trimester spontaneous abortion after ultrasound-proven viability.Obstet Gynecol. 1991; 78: 330-334
- The assessment of the gestational sac diameter, crown–rump length, progesterone and fetal heart rate measurements at the 10th gestational week to predict the spontaneous abortion risk.J Obstet Gynaecol Res. 2009; 35: 287-292
- Is trophoblastic thickness at the embryonic implantation site a new sign of negative evolution in first trimester pregnancy?.Hum Reprod. 2000 Jul; 15: 1629-1631
- Outcome of pregnancies with rapid embryonic heart rates in the early first trimester.Am J Roentgenol. 2000; 175: 67-69
- Predictable ultrasonographic findings of early abortion.J Korean Med Sci. 1992; 7: 34-39
- Prediction of abortion using three-dimensional ultrasound volumetry of the gestational sac and the amniotic sac in threatened abortion.J Clin Ultrasound. 2012; 40: 389-393
- Predicting first-trimester spontaneous abortion: ratio of mean sac diameter to crown-rump length compared to embryonic heart rate.J Reprod Med. 1994 Jun; 39: 459-462
- Evidence of early first-trimester growth restriction in pregnancies that subsequently end in miscarriage.BJOG. 2008; 115: 1273-1278
- Definitions and indicators in family planning maternal & child health and reproductive health used in the WHO regional office for Europe.World Health Organization, 2000
- Slow fetal heart rate may predict pregnancy outcome in first-trimester threatened abortion.Fertil Steril. 2004; 82: 227-229
- Fetal loss in threatened abortion after demonstration of fetal cardiac activity in a low socioeconomic population.J Obstet Gynaecol. 2010; 30: 622-625
- Prediction of spontaneous miscarriage risk by the use of first trimester ultrasound measurements and maternal serum progesterone level at the 7th week of pregnancy.Middle East Fertil Soc J. 2015; 20: 16-20
- Sonography of pregnancies with first-trimester bleeding and a viable embryo: a study of prognostic indicators by logistic regression analysis.Ultrasound Obstet Gynecol. 1996; 7: 165-169
- First trimester bradycardia: a sign of impending fetal loss.J Ultrasound Med. 1989 Oct; 8: 561-563
- Biochemical and ultrasonographic predictors of outcome in threatened abortion.Middle East Fertil Soc J. 2013; 18: 177-181
- Combined maternal serum inhibin A and embryonic/fetal heart rate for the prediction of pregnancy outcome in a first-trimester threatened abortion.J Med Assoc Thai. 2011; 94: 529
- The predictive value of first-trimester embryonic heart rates in infertility patients.Obstet Gynecol. 1997; 89: 934-936
- Embryonic heart rate in early pregnancy.J Clin Ultrasound. 1998; 26: 33-36
- Predictive value of earl embryonic cardiac activity for pregnancy outcome.Obstet Gynecol. 1991; 165: 11-14
- Can a smaller than expected crown–rump length reliably predict the occurrence of subsequent miscarriage in a viable first trimester pregnancy?.J Obstet Gynaecol Res. 2013; 39: 1449-1455
- The significance of crown-rump length measurement for predicting adverse pregnancy outcome of threatened abortion.Ultrasound Obstet Gynecol. 2001; 17: 510-512
- Uteroplacental circulation in patients with first-trimester threatened abortion.Fertil Steril. 2000; 73: 130-135
- Long-term prognosis of pregnancies in women with intrauterine hematomas.Obstet Gynecol. 1989; 74: 231-233
- Transvaginal sonography of the yolk sac in normal and abnormal pregnancy.J Clin Ultrasound. 1996; 24: 3-9
- Abnormal sonographic appearances of the yolk sac: which can be associated with adverse perinatal outcome?.Med Ultrasonogr. 2014; 16: 15
- Irregular yolk sac shape: is it really associated with an increased risk of spontaneous abortion?.J Ultrasound Med. 2011 Jan; 30: 31-36
- Obstetric outcome after threatened miscarriage with and without a hematoma on ultrasound.Obstet Gynecol. 2003; 102: 483-487
- Large intrauterine haematomata in threatened miscarriage: frequency and clinical consequences.BJOG. 1990; 97: 75-77
- Dating and growth in the first trimester.Best Pract Res Clin Obstet Gynaecol. 2009; 23: 439-452
- The value of the secondary yolk sac in predicting pregnancy outcome.J Obstet Gynaecol. 2005; 25: 245-247
Article info
Publication history
Published online: November 04, 2017
Accepted:
October 29,
2017
Received in revised form:
October 23,
2017
Received:
August 28,
2017
Identification
Copyright
Crown Copyright © 2017 Published by Elsevier Ireland Ltd. All rights reserved.
