Arch Gynecol Obstet (2014) 289:499504

DOI 10.1007/s00404-013-2979-5

MATERNAL-FETAL MEDICINE

Obstetric outcomes of patients with abortus imminens in the first

trimester
Ays e Nur Evrenos Ayse Nur Cakir Gungor
Cavidan Gulerman Emine Cosar

Received: 17 February 2012 / Accepted: 24 July 2013 / Published online: 4 August 2013
Springer-Verlag Berlin Heidelberg 2013

Abstract
Purpose We aimed to find out the effect of abortus imminens (AI) on obstetric outcomes of pregnancies which
continued beyond the 24th week of gestation.
Methods In this prospective study, 309 patients with AI
were divided into high-risk group (with a risk factor for
spontaneous abortus) (n = 92) and low-risk group (without
a risk factor) (n = 217). The control group (n = 308) was
chosen randomly.
Results In AI group, preterm delivery, preterm premature
rupture of membranes (PPROM), cesarean section (C/S)
delivery, postpartum uterine atony and need of a neonatal
intensive care unit (NICU) rates were significantly higher
than control group. Gestational diabetes mellitus, PPROM,
still birth, low APGAR scores were seen more frequently in
the high-risk patients than in the control group. Furthermore
in the high-risk group, preterm delivery, malpresentation,
C/S delivery and need of NICU were increased much more
than in the low-risk group. Gestational hypertension/preeclampsia, oligo/polyhydramniosis, intrauterine growth
retardation, placenta previa, abruption of placenta, chorioamnionitis, congenital abnormalities, delivery induction,
cephalopelvic disproportion, fetal distress and manual
removal of placenta were not different among the groups.
A. N. Evrenos
A. N. Cakir Gungor
C. Gulerman
Dr. Zekai Tahir Burak Women Health and Research Hospital,
Ankara, Turkey
A. N. Cakir Gungor
E. Cosar
Canakkale Onsekiz Mart University, Faculty of Medicine,
Department of Obstetrics and Gynecology, Canakkale, Turkey
A. N. Cakir Gungor (&)
Canakkale Onsekiz Mart University Hospital Kepez,
Canakkale, Turkey
e-mail: aysenurcakirgungor@gmail.com

Conclusions Patients with AI history, especially with

high-risk factors can have adverse obstetric and neonatal
results. So their antenatal follow-up has to be done cautiously for the early signs and symptoms of these
complications.
Keywords Abortus imminens
First trimester
bleeding
Obstetric outcomes
Neonatal outcomes

Introduction
Nearly 20 % of all pregnancies are complicated with first
trimester bleeding which is a risk factor for many complications [1, 2]. Half of those pregnancies are ended with
spontaneous abortus. Vaginal bleeding with a closed cervix
in early pregnancy is called AI. The diagnosis has to be
confirmed with the ultrasonographic imaging of gestational
sac and heart beating embryo or fetus [3].
Previous pregnancy loss, still birth and history of baby
with congenital abnormality increases the fetal loss possibility of the patient with first trimester bleeding. Patients
with previous abortus history have 20 % probability of
recurrence and three consecutive abortus increases the risk
to 50 %. In addition, maternal systemic diseases such as
DM and thyroid disfunction [4], infertility treatment [5],
maternal and paternal genetic defects [6] and increased
maternal and paternal age [7, 8] are risk factors for spontaneous abortus.
For the treatment of AI many treatments have been tried
such as bed rest, restricted sexual intercourse, progesterones and human chorionic gonadotropin. But generally
wait and see management is preferred [9, 10].
If the pregnancy continues after AI some obstetric
complications are seen more frequently than usually [11].

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Our aim was to detect whether the gestational complications and obstetric outcomes are effected in case of a
pregnancy complicated with AI and continued beyond the
24th week of gestation.

Materials and methods

In this study we examined the patients with AI diagnosis
who applied to Dr Zekai Tahir Burak Women Health and
Disease Education and Research Hospital antenatal clinic
between 1 September 2009 and 31 December 2009. Ethical
Committee approval and written consent of patients were
taken. Patients who were between 6th and 14th week of
gestation that had gestational sac, embryo or fetus on
ultrasonographic examination and had vaginal bleeding
without cervical dilatation and gynecologic pathology such
as cervical polyps and cervicitis that might cause vaginal
bleeding were diagnosed as AI. Pain and hematoma seen in
ultrasound examination were not used as diagnostic criteria. We examined 453 patients and divided them into two
groups according to having any risk factor prior to or early
in pregnancy period for spontaneous abortus as high-risk
group or not as low-risk group. Multiple pregnancies,
in vitro fertilization (IVF) pregnancies, uterine anomalies,
myoma uteri, cervical insufficiency and recurrent abortus
history were accepted as risk factors. Nearly all patients
with recurrent abortus history had thrombophilia. Of 453
patients, 140 of them were in the high-risk group and 313
were in the low-risk group.
Patients who had spontaneous abortus or intrauterine
exitus (n = 31) and patients that could not be followed up
(n = 17) were excluded and the remaining 92 patients
were included into the high-risk group.
Patients who had spontaneous abortus or intrauterine
exitus (n = 51) and patients that could not be followed up
(n = 45) were excluded and the remaining 217 patients
were included into the low-risk group.
As the control group, 362 patients that applied to our
antenatal clinic for routine examination at the same time
interval and that did not have an AI history in the ongoing
pregnancy were chosen randomly. Patients which could not
be followed up (n = 52) and had spontaneous abortus or
intrauterine exitus (n = 2) were excluded. So, 308 patients
formed the control group.
In our study, we compared the low-risk and high-risk
group with control group in respect of maternal age, previous obstetric history, gestational and delivery complications and neonatal outcomes prospectively. We did not use
any therapy for AI except bed rest and coitus restriction.
Only the patients who had recurrent abortus history with
thrombophilia used low molecular weight heparin from the
onset of the pregnancy.

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Arch Gynecol Obstet (2014) 289:499504

Data were analysed with SPSS 11.5 program. To search

the distribution of the continuous variables Shapiro Wilk
test was used. Descriptive statistics for continuous variables were defined as mean standard deviation or
median (minimummaximum). Categorical variables were
expressed as case number and percent. The significance of
the difference of means among groups was analysed by
one-way ANOVA test and the significance of medians
was analysed by KruskalWallis test. If a significant difference was found on one-way variance analysis or
KruskalWallis test, to find the cause of the difference
post hoc Tukey test or non-parametric multiple analog test
was used. Categorical variables were searched by Pearsons Chi-square test. P \ 0.05 was accepted as statistical
significance.

Results
In our study there were three groups, a high-risk AI group
(n = 92), a low-risk AI group (n = 217) and a control
group (n = 308). Demographic characteristics of the
groups are described in Table 1.
The median onset of the bleeding of the patients was 9th
and 10th week of gestation in the high-risk and the low-risk
group, respectively.
Abortus history in previous pregnancies was present in
65.2 % (n = 60) of the high-risk group, 22 % (n = 48) of
the low-risk group and 12.3 % (n = 38) of the control
group.
The distribution of the risk factors in the high-risk group
is described in Table 2.
Factors that might interfere with obstetric outcomes
such as chronic systemic disease and smoking were not
significantly different among groups (Table 3).
Groups were compared according to gestational complications in Table 4.
Pregnancies without complications were seen in 40.2 %
(n = 37) of the high-risk group, 50.2 % (n = 109) of the
low-risk group and 65.9 % (n = 203) of the control group.
Abnormal course of pregnancy was more prevalent in the
low-risk group (OR 1.9 95 % CI 1.752.13) (P \ 0.001)
and the high-risk group (OR 2.8 95 % CI 2.533.25)
(P \ 0.001).
Groups were compared according to their labour characteristics in Table 5.
Gestational age at the labour time was 36.4 (2642) for
the high-risk patients, 38.1 (2542) for the low-risk patients
and 38.6 (2742) for the control group (P \ 0.001).
Presentation abnormalities were significantly higher in
the low-risk group when compared with control group (OR
4.7 95 % CI 3.85.3) and highest in the high-risk group
(OR 18.7 95 % CI 16.221.1) (P \ 0.001).

Arch Gynecol Obstet (2014) 289:499504

501

Table 1 Demographic
characteristics of groups
Bold values are statistically
significant
a

Control group and high-risk

group difference is statistically
significant

Control group and low-risk

group difference is statistically
significant

High-risk and low-risk group

difference is statistically
significant

Maternal age

High-risk group
(n = 92)

Low-risk group
(n = 217)

Control group
(n = 308)

29.4 5.8

27.4 5.4

26.1 5.4

<0.001a,

Gravida

3 (113)

2 (17)

2 (16)

<0.001

Primigravid

20 (21.7 %)

78 (35.9 %)

109 (35.4 %)

0.034a,

Parity

1 (07)

1 (04)

1 (05)

0.281

Nulliparous

44 (47.8 %)

90 (41.5 %)

118 (38.3 %)

0.258

Alive children number

0 (03)

1 (04)

1 (05)

0.079

44 (47.8 %)

127 (58.5 %)

187 (60.7 %)

0.088

Abortus

2 (05)

0 (01)

0 (04)

<0.001a,

Curettage

0 (02)

0 (03)

0 (02)

0.934

Risk factors

High-risk group (n = 92)

Recurrent abortus history

53 (57.6 %)

Multiple pregnancy

29 (31.5 %)

Twin

27 (29.3 %)

Triplet

2 (2.2 %)

IVF

24 (26.1 %)

Uterine abnormality

2 (2.2 %)

Myoma uteri

5 (5.4 %)

Cervical

1 (1.1 %)

Table 3 Chronic systemic diseases and smoking properties of groups

High-risk
group
(n = 92)
Chronic systemic disease (%)
Smoking (%)

Have a living child

Table 2 Distribution of risk factors in high-risk group

12 (13)
4 (4.3)

Low-risk
group
(n = 217)

Control
group
(n = 308)

14 (6.5)

19 (6.2)

29 (13.8)

35 (11.4)

C/S delivery ratio was significantly higher in the lowrisk group when compared with the control group (OR 1.7
95 % CI 1.511.93) and the highest in the high-risk group
(OR 4.9 95 % CI 4.215.52) (P \ 0.0019). But there was
no statistically significant difference about cephalopelvic
disproportion and fetal distress ratios among the groups.
Postpartum atony was significantly higher in the lowrisk group than in the high-risk group (OR 4.7 95 % CI
4.215.22) (P \ 0.05).
Low APGAR score was defined as lower than 4 and 7 at
1st and 5th min, respectively. Low APGAR scores were
seen in 14.1 % (n = 13) of the high-risk group, 4.1 %
(n = 9) of the low-risk group and 2.3 % (n = 7) of the
control group. This was statistically significant for the
high-risk group (OR 6.9 95 % CI 6.027.82) (P \ 0.01).
NICU need occurred in 26 (28.3 %) of the high-risk
group, 8 (8.7 %) of them had respiratory distress, 6 (6.5 %)

b, c

a, c

of them had low birth weight, 12 (13 %) of them had both

of the problems. NICU need occurred in 36 (16.6 %) of the
low-risk group, 23 (10.6 %) of them had respiratory distress, 4 (1.8 %) of them had low birth weight, 6 (2.8 %) of
them had both of the problems and 3 (1.4 %) of them had
congenital abnormalities. NICU need occurred in 19
(6.2 %) of the control group, 12 (3.9 %) of them had
respiratory distress, 1 (0.3 %) of them had low birth
weight, 5 (1.6 %) of them had both of the problems and 1
(0.3 %) of them had congenital abnormalities.
NICU need was significantly higher in the low-risk
group when compared with the control group (OR 3 95 %
CI 2.563.43) and the highest in the high-risk group (OR
5.9 95 % CI 5.216.63) (P \ 0.001).
Etiology of AI is multifactorial. Some risk factors for AI
are cervical insufficiency, uterine abnormality, recurrent
abortus history, myoma uteri, multiple pregnancy and IVF
pregnancy. We divided the AI patients into two groups
according to the risk factors such as multiple pregnancies
which might interfere with the pregnancy outcomes.
Pregnancy complications independent from AI such as
PPROM and NICU might occur because of those risk
factors. So we tried to exclude this effect by forming a lowrisk group.
The prospective design of our study strengthens it, since
by this way a subjective symptom which could be forgotten
by the patient during the pregnancy is catched correctly
when it occurred. In addition, we marked the risk factors of
the patients so that we can clearly understand the effect of
AI independent of the underlying risk factors.
While Basama et al. [2] showed AI prevalence increment with age, other studies pointed out that there was no
relationship between them [12, 13]. In our study we also
found a relationship between increasing age and AI. Basama et al. [2] and Dadkhah et al. [13] found no relationship
between AI and gravida and parity. Although parity was
not significantly different among the groups in our study,
high-risk patients had more gravity perhaps because of the
previous abortus history.

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Arch Gynecol Obstet (2014) 289:499504

Table 4 Gestational
complications of groups

High-risk group
(n = 92)

Bold values are statistically

significant
a

Control group and high-risk

group difference is statistically
significant

High-risk and low-risk group

difference is statistically
significant

Control group and low-risk

group difference is statistically
significant

Low-risk group
(n = 217)

Control group
(n = 308)

Hypertension

8 (8.7 %)

15 (6.9 %)

15 (4.9 %)

0.346

Diabetes mellitus

9 (9.8 %)

8 (3.7 %)

7 (2.3 %)

0.005a,

Oligohydramnios

8 (8.7 %)

15 (6.9 %)

24 (7.8 %)

0.853

Polyhydramnios

1 (1.1 %)

5 (2.3 %)

7 (2.3 %)

0.725

Preterm labour

24 (26.1 %)

23 (10.6 %)

16 (5.2 %)

<0.001a,

Postterm labour

2 (2.2 %)

6 (2.8 %)

8 (2.6 %)

Membrane rupture

2 (2.2 %)

24 (11.1 %)

17 (5.5 %)

PPROM
IUGR

8 (8.7 %)

14 (6.5 %)

9 (2.9 %)

0.041

20 (9.2 %)

20 (6.5 %)

0.122

1 (1.1 %)

1 (0.5 %)

1 (0.3 %)

0.705

Placental Decollement
Chorioamnionitis

1 (1.1 %)
1 (1.1 %)

2 (0.9 %)

2 (0.6 %)

0.124
0.250

Intrauterine exitus

3 (3.3 %)

1 (0.5 %)

0 (0 %)

0.011a

2 (0.9 %)

12 (13.0 %)

b, c

0.956
0.007b,

Placenta previa

Congenital abnormality

0.123

Table 5 Labour complications among the groups

Cephalic presentation

High-risk group (n = 92)

Low-risk group (n = 217)

Control group (n = 308)

59 (64.1 %)

190 (87.6 %)

299 (97.1 %)

<0.001a,

b, c

a, b

C/S delivery

70 (76.1 %)

115 (53.0 %)

120 (39.0 %)

<0.001

Labour induction

19 (20.7 %)

56 (25.8 %)

77 (25.0 %)

0.616

Retained placenta

1 (1.1 %)

4 (1.8 %)

1 (0.3 %)

0.204

Uterine atony

2 (2.2 %)

10 (4.6 %)

3 (1.0 %)

0.028b

Bold values are statistically significant

a
b
c

Control group and high-risk group difference is statistically significant

Control group and low-risk group difference is statistically significant
High-risk and low-risk group difference is statistically significant

Systemic disease prevalence which might affect obstetric

outcomes was not significantly different among the groups.
Like Mulik et al. [14], we found no significant difference
between the low-risk group and control group about
smoking but in the high-risk group smoking rates were
lower than in the other groups. Perhaps it was because of the
responsive attitude of those patients due to their risk factors.
Because of the possible effect of bleeding on placental
dysfunction it was thought that there might be a relationship between AI and gestational hypertensive diseases. In a
multicenter prospective study, Weiss et al. [11] found that
there was a relationship between AI and preeclampsia (OR
1.5). On the other hand Wijesiriwardana et al. [12] and
Dadkhah et al. [13] found no relationship between them.
We also did not find a relationship between gestational
hypertensive conditions and AI.
Adverse obstetric outcomes can be seen in gestational
DM and pre pregnancy DM, especially in the uncontrolled
ones. A retrospective study by Ahkter et al. [15] found
increment in AI rates in diabetic pregnants (OR 1.4).

123

Interestingly, we found a strong relationship between highrisk AI and gestational DM (OR 4.6). It might be because
of the older mean age of this group. But this relationship
must be investigated by larger well designed controlled
prospective studies.
If the placentation site in the early pregnancy is placed
inferiorly, first trimester bleeding and placenta previa is
more prevalent. Wijesiriwardana et al. [12] found 1.8
times, Mulik et al. [14] found 3.3 times and Obed et al. [16]
found 2.5 times increase in placenta previa prevalence in
patients with AI history. But Davari-Tanha et al. [17] found
no difference between AI group and control group about
placenta previa prevalence in his prospective study. We
also did not found any significant difference about placenta
previa among groups.
AI caused placental disfunction which might lead to
placental decollement. Mulik et al. [14], Obed et al. [16]
and Johns et al. [18] found increment in placental
decollement in AI patients. But Wijesiriwardana et al. [12]
did not find increased risk for placental decollement for AI

Arch Gynecol Obstet (2014) 289:499504

patients. We also did not found any significant difference

about placenta previa among groups. This might be
because of the small sample size of our study.
Bleeding, disrupted chorioamniotic space, infection
caused by hematoma and decrement of cytotrophoblastic
invasion by spiral arterioles might induce preterm labour
and PPROM in AI patients. Various studies showed
increased risk of preterm labour for AI [11, 12, 14, 18]. We
found 2.1 times increase in low-risk patients and 6.4 times
increase in high-risk patients for preterm labour. While
some studies found increment of PPROM risk for those
patients [1, 13, 18], the others found no relationship
between AI and PPROM [14, 19]. We found a mild
increase for low-risk group that had no significance for
PPROM but a 3.2 times increase for high-risk group was
determined. It might be because of the underlying risk
factors of those patients.
Scar tissue formation beneath the placenta of AI patient
might cause IUGR. While Dadkhah et al. [13] and Tongsong et al. [19] showed no difference, Mulik et al. [14]
found 2.5 times increase for IUGR. We also found no
relationship between AI and IUGR.
Like the former studies we did not find relationship
between congenital anomalies and AI [19]. Perinatal
mortality of AI patients was increased 2.8 times in Muliks
study and 7.6 times in Davari-Tanhas study [14, 17]. But
in some studies there were no relationship between perinatal mortality and AI [12, 20]. We did not record the
perinatal mortality instead we found a 3.1 times increment
in intrauterine exitus in high-risk group.
Mean gestational age at term was lowest in high-risk
group because of the preterm births and PROM. While
Wijesiriwardana et al. [12] found a 1.3 times increase in
fetal malpresentation in AI group we found 4.7 times
increase in low-risk group and a 18.7 times in high-risk
group. This finding might be because of the underlying risk
factors of those patients.
Like Wijesiriwardana et al. [12] we did not found a relationship between labour induction and AI. Weiss et al. [11]
found a 1.3 times increase in C/S delivery in AI patients.
Wijesiriwardana et al. [12] showed a 1.3 times increase in
elective C/S deliveries but no difference about emergency
C/S deliveries. Mulik et al. [14] found no difference in C/S
deliveries. In our study, we found a 1.7 times increase in lowrisk group and 4.9 times increase in high-risk group in terms
of C/S deliveries. Increased C/S deliveries in low-risk group
might be because of increased non-cephalic presentation of
this group when compared to the control group. Increased
non-cephalic presentation of the low-risk group might be a
casual finding because of the small sample size.
Although some studies found an increase in placental
retention and manual extraction of placenta in AI patients
[12], we found no relationship between placental retention

503

and AI which might be because of the small sample size of

the study.
Although Wijesiriwardana et al. [12] found no relationship between postpartum atonia and AI, we showed a
4.7 times increase in the low-risk group but not in the highrisk group. Increment of uterine atonia in the low-risk
group might be a sign of common steps in the pathophysiology of AI and also uterine atony. So this is the most
striking result of our study.
Tongsongs study showed a 1.2 times increase in low
APGAR scores in AI patients [19]. In Wijesiriwardanas
study there was a 1.13 times increase in NICU need [12].
Spila et al. [20] found no relations between NICU need and
AI. We did not found a relationship between the low-risk
group and the control group in terms of low APGAR scores.
But 6.9 times increased low APGAR scores were determined
in the high-risk group. This increment might be because of
lower gestational age of this group. Need to NICU caused
mostly by respiratory distress increased 3 times in the lowrisk group and need to NICU usually because of prematurity
increased 5.9 times in the high-risk group.
Limitations of the current study are the absence of hematoma finding in the ultrasound image, amount and recurrence
of the bleeding and infections complicating the pregnancy that
might cause preterm labour which might lead to neonatal
complications. The objective parameter of fetal outcome pH
was not examined in our study. Instead we evaluated the
APGAR scores and NICU need for the newborn.
In conclusion, independent of the bleeding amount AI
patients have increased risk of adverse perinatal neonatal
outcomes; moreover, if the patient has risk factors prior to
or early in the pregnancy perinatal outcomes might be
worser and the patient and the doctor must be very careful
about those adverse outcomes.
Conflict of interest

We declare that we have no conflict of interest.

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