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Clinical and Experimental Obstetrics & Gynecology  2020, Vol. 47 Issue (1): 105-110    DOI: 10.31083/j.ceog.2020.01.5112
Original Research Previous articles | Next articles
Perinatal outcomes of second trimester antenatal genital bleeding
C. Chollet1, B. Andre1, M. Voglimacci1, A. Ghassani1, O. Parant1, 2, 3, P. Guerby1, *()
1CHU Toulouse, Pôle de Gynécologie Obstétrique, Hôpital Paule de Viguier, Toulouse, France
2Université de Toulouse III, UMR1027, Toulouse, France
3INSERM, UMR1027, Toulouse, France
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Abstract  

Objective: To evaluate the prognosis of singleton pregnancies complicated by genital bleeding during the 2nd trimester and to identify the factors associated with poor perinatal outcome. Materials and Methods: We conducted a retrospective study (January 2009 to December 2012), which included all women presenting with midtrimester bleeding (15 to 27 weeks of gestation). The cases were compared with women without bleeding, who delivered in our center during the same period. Results: Ninety-seven women were included (0.57% of the overall singleton births). An underlying placental cause was discovered by ultrasound in 56% of the cases (low-lying placenta, partially detached placenta or a combination of both of these pathologies). We report a significantly increased rate of preterm birth (47.4% vs. 12.2%; RR=3.9), perinatal mortality (11.3% vs. 1.3%; RR=8.8), PPROM (16.5% vs. 3.7%; RR=4.5; CI 95% [2.8-7.1]), and cesarean section (42.3% vs. 21%; RR=2; CI 95% [1.6-2.5]) in the bleeding group. The factors associated with preterm birth were recurrent bleeding (OR=4.7), gestational age > 22 WG at the first bleeding (OR=3.7), and low-lying placenta. Conclusion: Despite a low incidence, the occurrence of bleeding in the 2nd trimester of pregnancy should alert the physician because of increased perinatal morbimortality. These patients may thus require increased monitoring.

Key words:  Vaginal bleeding      Ultrasound      Second trimester of pregnancy      Adverse pregnancy outcomes      Preterm delivery     
Published:  15 February 2020     
*Corresponding Author(s):  P. Guerby     E-mail:  paul.guerby@gmail.com

Cite this article: 

C. Chollet, B. Andre, M. Voglimacci, A. Ghassani, O. Parant, P. Guerby. Perinatal outcomes of second trimester antenatal genital bleeding. Clinical and Experimental Obstetrics & Gynecology, 2020, 47(1): 105-110.

URL: 

https://ceog.imrpress.com/EN/10.31083/j.ceog.2020.01.5112     OR     https://ceog.imrpress.com/EN/Y2020/V47/I1/105

Figure 1  — Bimodal distribution of the gestational age at time of delivery.

Table 1  — Main obstetrical and perinatal complications associated with the occurrence of a hemorrhage during the 2nd trimester of pregnancy (univariate analysis).
Bleeding during
2nd trimester (N=97)
Control group
(N=16, 912)
RR [CI 95%] p
Number of cases (%)
Preterm birth 46 (47.4) 2061 (12.2) 3.9 [3.1 - 4.8] <0.0001
Preterm <32 WG 36 (37.1) 908 (5.3) 6.9 [5.3 - 9] <0.0001
PPROM 16 (16.5) 622 (3.7) 4.5 [2.8 - 7.1] <0.0001
Cesarean section 41 (42.3) 3554 (21) 2.0 [1.6 - 2.5] <0.0001
Perinatal mortality 11 (11.3) 218 (1.3) 8.8 [5 - 15.6] <0.0001
Intrauterine mortality 8 (8.2) 130 (0.8) 10.7 [5.4 21.3] <0.0001
Early neonatal mortality 3 (3.1) 88 (0.5) 5.9 [1.9 - 18.5] 0.015
Table 2  — Risk of preterm birth associated with hemorrhages during the 2nd trimester of pregnancy according to the presumed origin of bleeding and associated factors.
All preterm births Severe prematurity (28 to 32 WG) Extreme prematurity (22 to 27 WG)
% p % p % p
Abundance of bleeding Moderate to heavy 52.4 0.11 42.9 0.039 28.6 0.053
Light 34.5 20.6 10.3
Gestational age at first episode >22 WG 58.8 0.018 51 0.003 35.3 0.005
<22 WG 34.8 21.7 10.9
Recurrence of bleeding Yes 60.4 0.014 47.9 0.035 27.1 0.47
No 35.4 27.1 20.8
Number of episodes More than 3 64.7 0.012 52.9 0.018 26.5 0.64
1 or 2 38.1 28.6 22.2
Partially detached placenta Yes 66.7 0.15 58.3 0.12 25 1
No 44.7 34.1 23.5
Low-lying placenta Yes 37.5 0.17 21.9 0.029 12.5 0.069
No 52.3 44.6 29.2
Partially detached and low-lying placenta Yes 63.6 0.25 54.5 0.32 36.7 0.28
No 45.3 34.9 22.1
All placental causes Yes 49.1 0.71 36.3 0.86 20 0.33
No 45.2 38.1 28.6
Characterization of low-lying placenta III or IV 50 0.47 25 0.49 15 0.7
I or II 39.1 34.8 21.7
Table 3  — Risk of preterm premature rupture of membranes associated with hemorrhages during the 2nd trimester of pregnancy according to the presumed origin of the bleeding and associated factors.

Preterm premature rupture of membranes

%

P
Clinical Characteristics Abundance of bleeding Moderate to heavy
16.9 1
Light
17.2
Gestational age at first episode > 22 WG
20 0.44
< 22 WG
14
Recurrence of bleeding Yes
21.7 0.27
No
13
Number of episodes More than 3
25 0.15
1 or 2
13.1
Ultrasound Diagnosis Partially detached placenta Yes
50 0.005
No
12.3
Low-lying placenta Yes
0 0.002
No
25.4
Partially detached and low-lying placenta Yes
10 1
No
18.1
All placental causes Yes
13.5 0.28
No
22
Characterization of low-lying placenta III or IV
0 1
I or II
4.5 %
Table 4  — Perinatal mortality, intrauterine fetal death, and early neonatal mortality resulting from hemorrhage during the 2nd trimester of pregnancy according to the presumed origin of the bleeding and associated factors.

Perinatal mortality

Intrauterine fetal death

Early neonatal mortality
% P % P % P
Clinical Characteristics Abundance of bleeding Moderate to heavy
9.5 0.72 7.9 0.70 1.6 0.53
Light
13.8 10.3 3.4
Gestational age at first episode >22 WG
7.8 0.25 5.9 0.47 2 0.60
<22 WG
15.2 10.9 4.3
Recurrence of bleeding Yes
12.5 0.75 10.4 0.71 2.1 1
No
10.4 6.3 3.2
Number of episodes More than 3
14.7 0.51 11.8 0.45 2.9 1
1 or 2
9.5 6.3 3.2
Ultrasound Diagnosis Partially detached placenta Yes
50 0.005 16.7 0.28 0 1
No
12.3 7.1 3.5
Low-lying placenta Yes
0 0.002 9.4 1 0 0.55
No
25.4 7.7 4.6
Partially detached and low-lying placenta Yes
9.1 1 9.1 1 0 1
No
11.6 8.1 3.5
All placental causes Yes
10.9 1 10.9 0.46 0 0.078
No
11.9 4.8 7.1
Characterization of low-lying placenta III or IV
10 1 10 1 0 -
I or II
8.7 8.7 0
Table 5  — Factors associated with prematurity, preterm premature rupture of the membranes, and cesarean section (multivariate analysis)

Odds Ratio

95% CI

P value

Prematurity
Gestational age at the 1st episode 3.7 1.4 - 9.5 0.007
Recurrence of bleeding 4.7 1.8 - 12.6 0.002
Low-lying placenta 0.4 0.1 - 1 0.047

Preterm Premature Rupture of Membranes
Partially detached placenta 7.1 2 - 25.4 0.001

Cesarean Section
Recurrence of bleeding
2.4 1.0 - 5.5 0.04
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