Review article| Volume 220, P122-131, January 2018

Prediction of miscarriage in women with viable intrauterine pregnancy—A systematic review and diagnostic accuracy meta-analysis

  • Rekha N. Pillai
    Women’s and Children’s CMG, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, United Kingdom

    Department of Health Sciences, University of Leicester, Leicester, LE1 7RH, United Kingdom
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  • Justin C. Konje
    Department of Obstetrics and Gynecology, Sidra Medical and Research Centre, PO Box 26999, Doha, Qatar
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  • Matthew Richardson
    National Institute of Health Research, Leicester Respiratory Biomedical Research Unit, University Hospitals of Leicester NHS Trust, LE3 9QP, United Kingdom
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  • Douglas G. Tincello
    Women’s and Children’s CMG, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, United Kingdom

    Department of Health Sciences, University of Leicester, Leicester, LE1 7RH, United Kingdom
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  • Neelam Potdar
    Corresponding author at: Department of Gynaecology, Kensington Building, Leicester Royal Infirmary, Leicester, LE1 5WW, United Kingdon.
    Women’s and Children’s CMG, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, United Kingdom

    Department of Health Sciences, University of Leicester, Leicester, LE1 7RH, United Kingdom
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Published:November 04, 2017DOI:


      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.


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