First-trimester vaginal bleeding and complications later in pregnancy.
OBJECTIVE
To evaluate the association of first-trimester bleeding without miscarriage and complications later in the first pregnancy as well as in the next pregnancy.


METHODS
In a retrospective, registry-based cohort study, we identified women delivering in Denmark from 1978 to 2007 with a first singleton pregnancy (n=782,287) and first and second singleton pregnancies (n=536,419). First-trimester bleeding is defined as vaginal bleeding before 12 full weeks of gestation. We employed multivariate logistic regression with adjustment for maternal age and calendar year.


RESULTS
First-trimester bleeding increased the risk of delivery in weeks 32-36 from 3.6% to 6.1% (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.57-1.77) and in weeks 28-31 from 0.3% to 0.9% (OR 2.98; 95% CI 2.50-3.54) and increased the risk of placental abruption from 1.0% to 1.4% (OR 1.48; 95% CI 1.30-1.68). First-trimester bleeding in the first pregnancy increased the risk of recurrence in the second pregnancy from 2.2% to 8.2% (OR 4.05; 95% CI 3.78-4.34), preterm delivery from 2.7% to 4.8% (OR 1.83; 95% CI 1.67-2.00), and placental abruption from 0.9% to 1.0% (OR 1.29; 95% CI 1.07-1.56) in the second pregnancy.


CONCLUSIONS
Women with first-trimester bleeding in the first pregnancy have an increased risk of complications later in the first pregnancy and of recurrence of first-trimester bleeding and other complications in the second pregnancy.
Lykke
Jacob Alexander
JA
From the Department of Obstetrics and Gynecology, Roskilde Hospital, Roskilde; and the Department of Obstetrics and Gynecology, Rigshospitalet, Copenhagen, Denmark.
Dideriksen
Katrine Lehrmann
KL
Lidegaard
Øjvind
Ø
Langhoff-Roos
Jens
J
D000328:Adult; D015986:Confounding Factors, Epidemiologic; D003718:Denmark / Q000453:epidemiology; D005260:Female; D005322:Premature Rupture of Fetal Membranes / Q000453:epidemiology; D006801:Humans; D007752:Obstetric Labor, Premature / Q000453:epidemiology; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology*; D011256:Pregnancy Outcome / Q000453:epidemiology; D011261:Pregnancy Trimester, First; D012008:Recurrence; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D014592:Uterine Hemorrhage / Q000453:epidemiology*; D055815:Young Adult
Everett C. Incidence and outcome of bleeding before the 20th week of pregnancy: prospective study from general practice. BMJ 1997;315:32–4.
Hasan R, Baird DD, Herring AH, Olshan AF, Jonsson Funk ML, Hartmann KE. Association between first-trimester vaginal bleeding and miscarriage. Obstet Gynecol 2009;114:860–7.
van Oppenraaij RH, Jauniaux E, Christiansen OB, Horcajadas JA, Farquharson RG, Exalto N, et al. Predicting adverse obstetric outcome after early pregnancy events and complications: a review. Hum Reprod Update 2009;15:409–21.
Saraswat L, Bhattacharya S, Maheshwari A, Bhattacharya S. Maternal and perinatal outcome in women with threatened miscarriage in the first trimester: a systematic review. BJOG 2010;117:245–57.
Ananth CV, Savitz DA. Vaginal bleeding and adverse reproductive outcomes: a meta-analysis. Paediatr Perinat Epidemiol 1994;8:62–78.
Hertz JB, Heisterberg L. The outcome of pregnancy after threatened abortion. Acta Obstet Gynecol Scand 1985;64:151–6.
Williams MA, Mittendorf R, Lieberman E, Monson RR. Adverse infant outcomes associated with first-trimester vaginal bleeding. Obstet Gynecol 1991;78:14–8.
Mulik V, Bethel J, Bhal K. A retrospective population-based study of primigravid women on the potential effect of threatened miscarriage on obstetric outcome. J Obstet Gynaecol 2004;24:249–53.
Johns J, Jauniaux E. Threatened miscarriage as a predictor of obstetric outcome. Obstet Gynecol 2006;107:845–50.
Weiss JL, Malone FD, Vidaver J, Ball RH, Nyberg DA, Comstock CH, et al. Threatened abortion: a risk factor for poor pregnancy outcome, a population-based screening study. Am J Obstet Gynecol 2004;190:745–50.
Wijesiriwardana A, Bhattacharya S, Shetty A, Smith N, Bhattacharya S. Obstetric outcome in women with threatened miscarriage in the first trimester. Obstet Gynecol 2006;107:557–62.
Hossain R, Harris T, Lohsoonthorn V, Williams MA. Risk of preterm delivery in relation to vaginal bleeding in early pregnancy. Eur J Obstet Gynecol Reprod Biol 2007;135:158–63.
Johns J, Hyett J, Jauniaux E. Obstetric outcome after threatened miscarriage with and without a hematoma on ultrasound. Obstet Gynecol 2003;102:483–7.
Lockwood CJ, Krikun G, Rahman M, Caze R, Buchwalder L, Schatz F. The role of decidualization in regulating endometrial hemostasis during the menstrual cycle, gestation, and in pathological states. Semin Thromb Hemost 2007;33:111–7.
Redman CW, Sargent IL. Pre-eclampsia, the placenta and the maternal systemic inflammatory response: a review. Placenta 2003;24:S21–7.
Norwitz ER. Defective implantation and placentation: laying the blueprint for pregnancy complications. Reprod Biomed Online 2006;13:591–9.
Andersen TF, Madsen M, Jørgensen J, Mellemkjoer L, Olsen JH. The Danish National Hospital Register: a valuable source of data for modern health sciences. Dan Med Bull 1999;46:263–8.
Marsál K, Persson PH, Larsen T, Lilja H, Selbing A, Sultan B. Intrauterine growth curves based on ultrasonically estimated foetal weights. Acta Paediatr 1996;85:843–8.
Klemmensen AK, Olsen SF, Osterdal ML, Tabor A. Validity of preeclampsia-related diagnoses recorded in a national hospital registry and in a postpartum interview of the women. Am J Epidemiol 2007;166:117–24.
Yang J, Hartmann KE, Savitz DA, Herring AH, Dole N, Olshan AF, et al. Vaginal bleeding during pregnancy and preterm birth. Am J Epidemiol 2004;160:118–25.
Ananth CV, Oyelese Y, Prasad V, Getahun D, Smulian JC. Evidence of placental abruption as a chronic process: associations with vaginal bleeding early in pregnancy and placental lesions. Eur J Obstet Gynecol Reprod Biol 2006;128:15–21.
Eskild A, Vatten LJ. Abnormal bleeding associated with preeclampsia: a population study of 315,085 pregnancies. Acta Obstet Gynecol Scand 2009;88:154–8.
Hustin J, Jauniaux E, Schaaps JP. Histological study of the materno-embryonic interface in spontaneous abortion. Placenta 1990;11:477–86.
Kim YM, Chaiworapongsa T, Gomez R, Bujold E, Yoon BH, Rotmensch S, et al. Failure of physiologic transformation of the spiral arteries in the placental bed in preterm premature rupture of membranes. Am J Obstet Gynecol 2002;187:1137–42.
Kim YM, Bujold E, Chaiworapongsa T, Gomez R, Yoon BH, Thaler HT, et al. Failure of physiologic transformation of the spiral arteries in patients with preterm labor and intact membranes. Am J Obstet Gynecol 2003;189:1063–9.
Lyall F. Priming and remodelling of human placental bed spiral arteries during pregnancy: a review. Placenta 2005;26:S31–6.
Redman CW, Sargent IL. Latest advances in understanding preeclampsia. Science 2005;308:1592–4.
Lockwood CJ. Testing for risk of preterm delivery. Clin Lab Med 2003;23:345–60.
Romero R, Espinoza J, Kusanovic JP, Gotsch F, Hassan S, Erez O, et al. The preterm parturition syndrome. BJOG 2006;113:17–42.
French JI, McGregor JA, Draper D, Parker R, McFee J. Gestational bleeding, bacterial vaginosis, and common reproductive tract infections: risk for preterm birth and benefit of treatment. Obstet Gynecol 1999;93:715–24.
Lykke JA, Paidas MJ, Langhoff-Roos J. Recurring complications in second pregnancy. Obstet Gynecol 2009; 113:1217–24.