1. Dr.Zhila Abedi Asl MD.Fellowship of lnfertility Tehran medical university

2. Categories of spontaneous abortion Threatened abortion Inevitable abortion Complete or incomplete abortion Missed abortion Recurrent abortion

3. Threatened abortion Definition Any bloody vaginal discharge or bleeding during 1 st half of pregnancy Bleeding is frequently slight, but may persist for days or weeks Frequency Extremely common (one out of four or five pregnant women) Prognosis Approximately ½ will abort Risk of preterm delivery, low birthweight, perinatal death ↑ Risk of malformed infant does not appear to be increased

4. Threatened abortion Symptoms Usually bleeding begins first throuhg a closed cervical os Often painless or suprapubic pain Ph/E; uterine size appropriate for GA FHR detectable with US

5. Adverse outcome Miscarriage Preterm birth PROM Growth retardation Antepartum bleeding

6. Etiology Genetic or chromosomal abnormality Congenital anomaly Trauma Host factors Unexplained

7. Risk factors age Previous spontaneous abortion Smoking Alcohol Gravidity Cocaine NSAID Fever Caffeine Prolonged ovulation to implantation interval Prolonged time to pregnancy Low folat level Maternal weight Celiac disease

8. Treatment Bed rest & acetaminophen-based analgesia Progesterone (IM) or synthetic progestational agent (PO or IM) Lack of evidence of effectiveness Often results in no more than a missed abortion D-negative women with threatened abortion Probably should receive anti-D immunoglobulin

9. RCOG GUIDELINE In many countries, women with bleeding and/or pain will be treated with progesterone or progestogens to try and decrease the risk of miscarriage. The evidence for the effectiveness of this treatment has been inconclusive, but data from a meta-analysis of several small studies suggest that progestogens are better than placebo. However, there are theoretical risks to prescribing any treatment in pregnancy and for many practitioners this will be a major change in practice. The lack of strong evidence makes this a priority area for research

10. Progestogen for treating threatened miscarriage. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005943 Cochrane Database Syst Rev. MAIN RESULTS: Two studies (84 participants) were included in the meta-analysis. In one study, all the participants met the inclusion criteria and in the other study, only the subgroup of participants who met the inclusion criteria was included in the meta-analysis. There was no evidence of effectiveness with the use vaginal progesterone compared to placebo in reducing the risk of miscarriage (relative risk 0.47; 95% confidence interval (CI) 0.17 to 1.30). AUTHORS' CONCLUSIONS: Based on scarce data from two methodologically poor trials, there is no evidence to support the routine use of progestogens for the treatment of threatened miscarriage. Information about potential harms to the mother or child, or both, with the use of progestogens is lacking. Further, larger, randomized controlled trials on the effect of progestogens on the treatment of threatened miscarriage, which investigate potential harms as well as benefits, are needed

11. Cochrane Database Syst Rev.Cochrane Database Syst Rev. 2011 Dec 7;(12):CD005943. MAIN RESULTS: We included four studies (421 participants) in the meta-analysis. In three studies all the participants met the inclusion criteria and in the fourth study, we included only the subgroup of participants who met the inclusion criteria in the meta-analysis. There was evidence of a reduction in the rate of spontaneous miscarriage with the use of progestogens compared to placebo or no treatment (risk ratio (RR) 0.53; 95% confidence interval (CI) 0.35 to 0.79). There was no increase in the rate of antepartum haemorrhage (RR 0.76; 95% CI 0.30 to 1.94), or pregnancy-induced hypertension (RR 1.00; 95% CI 0.54 to 1.88) for the mother. The rate of congenital abnormalities was no different between the newborns of the mothers who received progestogens and those who did not (RR 0.70; 95% CI 0.10 to 4.82). AUTHORS' CONCLUSIONS: The data from this review suggest that the use of progestogens is effective in the treatment of threatened miscarriage with no evidence of increased rates of pregnancy-induced hypertension or antepartum haemorrhage as harmful effects to the mother, nor increased occurrence of congenital abnormalities on the newborn. However, the analysis was limited by the small number and the poor methodological quality of eligible studies (four studies) and the small number of the participants (421), which limit the power of the meta-analysis and hence of this conclusion

12. Human chorionic gonadotrophin for threatened miscarriage Cochrane Database Syst Rev. 2010 May 12;(5):CD00742 Cochrane Database Syst Rev. MAIN RESULTS: Three studies (312 participants) were included in the review, one of which was of poor methodological quality. The meta-analysis showed that there was no statistically significant difference in the incidence of miscarriage between hCG and 'no hCG' (placebo or no treatment) groups (Risk ratio (RR) 0.66; 95% confidence interval (CI) 0.42 to 1.05). When hCG and bed rest alone were compared, there was a significant reduction in the risk of miscarriage (RR 0.47; 95% CI 0.27 to 0.82). This result should be interpreted with caution, as one of the two trials from which this result is derived was of poor methodological quality. There was no report of adverse effects of hCG on mother or baby. More good quality RCTs are urgently needed to assess the effects of hCG in threatened miscarriage. AUTHORS' CONCLUSIONS: The current evidence does not support the routine use of hCG in the treatment of threatened miscarriage

13. DR. ABEDI