INTRODUCTION: Nearly (27 to 30%) twenty seven to thirty percent of all pregnant women in their rst trimester complain of bleeding. In these women who present with bleeding per vagina, during their rst trimester several diagnostic possibilities can be considered. By mere clinical examination & also history, denitive diagnosis is usually impossible. The three major causes of bleeding in rst trimester are abortion, ectopic pregnancy & molar pregnancy. USG helps in assessing the type of abortion. Early diagnosis & better management including post evacuation follow up of molar & ectopic pregnancy. MATERIALS & METHODS: The main sources of data for this study were 50 cases of pregnant women who presented with bleeding per vaginum during the rst trimester between MAY 2018 to JUNE 2019 in the department of obstetrics & gynaecology at Shri Vasant Rao Naik Govt Medical College, Yavatmal,M.S. All patients referred to the Dept of Radio diagnosis with clinically suspected rst trimester bleeding were evaluated with clinical history, clinical examination & ultrasonography as per st&ard proforma.This study was approved by the ethical committee of the institution.Relevant images were recorded. INCLUSION CRITERIA: All patients with clinically suspected rst trimester bleeding (< 12 completed weeks) EXCLUSION CRITERIA: All non-obstetrical causes of vaginal bleeding. All patients with more than 12 completed weeks of gestation. OBSERVATION & RESULTS: Table 1: showing ndings of USG examination On USG examination, 28 cases (56%) out of 50 showed Gestational sac out of which 18 cases were of threatened abortion. Out of 21 cases in which Fetal node was visualized, 18 cases showed fetal cardiac activity. 2 cases with absent fetal cardiac activity were diagnosed as inevitable abortion & 1 case as missed abortion. Of the 3 cases which demonstrated less liquor, 2 cases were inevitable abortion & 1 case was threatened abortion. Yolk sac was detected in 12 cases. All were diagnosed as threatened abortion. Placenta was visualized in 6 cases & all were of more than 11 weeks gestation. WE HAVE DIVIDED OUR STUDY GROUP INTO 3 MAIN CATEGORIES FOR THE PURPOSE OF STATISTICAL CORRELATION. THE 3 GROUPS ARE: Viable intrauterine pregnancies ROLE OF USG IN EVALUATION OF FIRST TRMESTER BLEEDING PERVAGINUM IN A RURAL TERTIARY CARE HOSPITAL IN MAHARASHTRA, INDIA: A PROSPECTIVE OBSERVATIONAL STUDY Original Research Paper Dr. Rohidas Chavan Professor & Head, Department Of Obstetrics & Gynaecology, Shri Vasantrao Naik Govt Medical College, Yavatmal Obstetrics & Gynaecology BACKGROUND: Vaginal bleeding in the rst trimester of pregnancy is a common obstetric problem.The common causes of bleeding during rst trimester include various types of abortions, ectopic pregnancy & molar pregnancy. Clinical history & pelvic examination are inadequate in assessing the cause & prognosis. OBJECTIVE of this study is to evaluate the role of USG in the evaluation of patients with rst trimester bleeding & to prognosticate & predict the status of abnormal pregnancies. METHODS: The study was carried out on 50 pregnant women who presented with bleeding per vaginum in rst trimester of pregnancy visiting obstetrics & gynaecology department . The patients were included on the basis of clinically suspected rst trimester bleeding (< 12 completed weeks). All non-obstetrical causes of vaginal bleeding & those with more than 12 completed weeks of gestation were excluded from the study. All patients referred to the Dept of Radio diagnosis with clinically suspected rst trimester bleeding were evaluated with clinical history, clinical examination & ultrasonography. RESULTS: Of the fty cases of rst trimester bleeding, 26 cases were diagnosed as threatened abortion clinically, out of which only 12 cases were conrmed. USG examination conrmed 12 cases of clinically suspected threatened abortions & aids in correctly diagnosing 8 cases which were missed on clinical examination. 12 cases out of 18 threatened abortions continue to term gestation with a successful outcome of 66%. All cases of threatened abortion (n=18), incomplete abortion (n=10), missed abortion (n=4), ectopic (n=4), inevitable abortion (n=4), blighted ovum (n=2), & HM (n=2), were correctly diagnosed on USG. 48 out of 50 cases were correctly diagnosed on USG compared to 18 out of 50 cases on clinical diagnosis with a disparity of 64%. 4 out of 5 proved ectopic pregnancies were correctly diagnosed both on USG & clinical examination. CONCLUSION: USG is a non-invasive, non-ionizing, without any proved harmful effects on the developing fetus & easily available method of investigation to assess the patients with rst trimester bleeding which is highly accurate in diagnosing the actual causes of bleeding & guides the clinician in choosing the appropriate line of management & prevents mismanagement of the cases. In the present study, 48 out of 50 cases were correctly diagnosed on USG compared to 18 out of 50 cases on clinical diagnosis with a disparity of 64%. ABSTRACT KEYWORDS : First Trimester Bleeding, Usg Examination, Clinical Examination VOLUME-9, ISSUE-2, FEBRUARY-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Dr. Sushma Gore* Associate Professor, Department Of Obstetrics & Gynaecology, Shri Vasantrao Naik Govt Medical College, Yavatmal *Corresponding Author Dr. Arshiya Syed Post Graduate Student USG examination Number (n=50) % 1.G sac 28 56.0 2.Foetal pole 21 42.0 3.Cardiac activity 18 36.0 4.Yolk sac 12 24.0 5.Subchorionic bleed 7 14.0 6.Placenta 6 12.0 7.Less Liquor 3 6.0 18 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS Nonviable intrauterine pregnancy Ectopic pregnancy/gestation The groups were formed on the basis of the subsequent line of management in the particular cases. All cases of viable intrauterine pregnancies were to be followed up without intervention; while other cases were managed as appropriate based on the USG ndings. Table 2: Correlation of USG diagnosis with Final diagnosis- an evaluation In present study, 18 cases of viable intrauterine pregnancies were correctly diagnosed on USG with zero false positive & zero false negativity with sensitivity, specicity, PPV, NPV & accuracy of 100% each. 80% of ectopic pregnancies were correctly diagnosed with a specicity & PPV of 100 % whereas 1 case was missed on sonography with a sensitivity of 80% & NPV of 97.83% with an accuracy of 98%. Of the nonviable pregnancies diagnose on USG were conf irmed with a sensitivity & NPV of 100% whereas 1 case of false positive complete abortion was made on USG with a specicity of 95.65%, PPV of 96.43% & accuracy of 98%. USG diagnosis proved to be very accurate on statistical evaluation with a very signicant p value of <0.001. Table 3: Correlation of Clinical diagnosis with USG diagn osis- an evaluation Sen. Sensitivity; Sp: Specicity, PPV: Positive predictive Value; NPV: Negative Predictive value & Accuracy In present study, when compared to the USG diagnosis, clinical diagnosis has true positive of 15, false positive of 11 & true negative of 21 in diagnosing viable pregnancies that constitutes threatened abortion . Clinical diagnosis has high false negative & true negative in diagnosing non viable intrauterine pregnancies. Our study has a sensitivity of 83.3, PPV of 57.7 & accuracy of 72% in diagnosing viable pregnancies with a very signicant p value (< 0.001). Clinical diagnosis of ectopic pregnancy has good specicity (97.93%), NPV (97.83%) & accuracy (96%) with p value < 0.001 which is very signicant. Clinical diagnosis has got very poor statistical correlation when compared to USG diagnosis in evaluating non viable intrauterine pregnancies with a sensitivity of 57.14 %, NPV of 60% & accuracy 68.0 % which shows a p value of 0.052. This data shows that USG diagnosis is considerably more accurate than clinical diagnosis. Table 4: Treatment Out of 50 cases of in our study, 30cases were managed conservatively. All threatened cases were managed with bed rest either in the hospital on in the home. All 4 cases of inevitable abortion were spontaneously aborted on expectant management. 1 out of the 4 missed abortions & 2 out of the 5 ectopic pregnancies were managed conservatively. All cases of complete abortion were treated with bed rest. 3 cases out of 5 of ectopic pregnancy were treated by laparotomy. All incomplete abortions & anembryonic gestation were surgically evacuated. 2 cases of H mole were treated by D&C. DISCUSSION: Bleeding per vaginum in the rst trimester is 1 of the most common obstetric problems. By mere clinical history & examination denitive diagnosis is usually impossible. The causes of bleeding are many & cover a spectrum of conditions ranging from a viable pregnancy to non-viable pregnancy. Ultrasonography has opened new dimensions in early pregnancy bleeding so that specic treatment, medical or surgical, can be immediately instituted. Accurate diagnosis of nature of the pregnancy (viable or non-viable) can avoid unnecessary hormonal treatment & prolonged hospit aliz ation. It also indicates the need for a Dilatation & Curettage by diagnosing retained products of conception in the uterine cavity. Ultrasonographic examination provides good index for evacuation in cases of abortion. Curettage is necessary if residual contents are seen but not when the uterus though bulky appears empty. CONCLUSION : Vaginal bleeding in the rst trimester of pregnancy is a common obstetric problem & is a cause of anxiety & worry both to the patients & the obstetrician. Clinical history & pelvic examination are inadequate in assessing the cause & the prognosis.USG is a non- invasive, non-ionizing & easily available method of investigation to assess the patients with rst trimester bleeding which is highly accurate in diagnosing the actual causes of bleeding & guides the clinician in choosing the appropriate line of management & prevents mismanagement of the cases. USG can assess some ndings which are helpful in predicting the prognosis of the pregnancy. REFERENCES: 1. Cunningham FG, editor. Williams’s obstetrics 21 edition. New York; McGraw- Hill; 2001. P-866. 2. Nyberg DA, Filly. RA, Duart E, Filho DL, Laing FC, et al Abnormal pregnancy: Early diagnosis by US & serum chorionic gonadotropin levels. Radiology 1986; 158: 393-6 3. J.W.S Baron Rayleigh, “On the Theory of Sounds, Philos. Trans” 1971, 161, 77- 118. 4. Curie. J.P., Curie. (1880) Développement par pression de l’é’lectricite polaire dans les cristaux hémièdres à faces inclinées. C.R. Acad. 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VOLUME-9, ISSUE-2, FEBRUARY-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Parameters Sen. Sp PPV NPV Accuracy P value Viable intrauterine pregnancy 100.00 100.00 100.00 100.00 100.00 <0.001** Ectopic Pregnancy 80.00 100.00 1000.00 97.83 98.00 <0.001** Nonviable intrauterine pregnancy 100.00 95.65 96.43 100.00 98.00 <0.001** Parameters Sen. Sp PPV NPV Accuracy P value Viable intrauterine pregnancy 83.33 65.63 57.69 87.50 72.00 <0.001** Ectopic Pregnancy 75.00 97.93 75.00 97.83 96.00 <0.001** Nonviable intrauterine pregnancy 57.14 81.82 80.00 60.0 68.00 0.052+ Treatment Number (n=50) % Conservative 30 60 Laparatomy 3 6.0 D & C 17 34.0 X 19GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS Brooke Jeffrey. Ultrasonographic differentiation of the Gestational sac of early intrauterine pregnancy from pseudo-gestational sac of ectopic pregnancy. Radiology; 1983. 146:755-759. 12. Keith G. Bernard Peter L. Cooperberg. Sonographic differentiation between blighted ovum & early viable pregnancy. AJR March 1985. 144:597-602 13. Rajan R, Rajan V; Ultrasonography in First trimester bleeding. J Obstet Gynecol India; 1987. 37:457-461 14. David A Nyberg, Roy A Filly, Faye C. Laing. Threatened abortion: Sonographic distinction of normal & abnormal gestation sacs. Radiology; 1986. 158:397-400. 15. Jaideep Malhotra, K Saxena & N Malhotra. USG evaluation of rst trimester bleeding per vaginum: J Obstetrics & Gynecology of India, 1987. 37:341- 343 VOLUME-9, ISSUE-2, FEBRUARY-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra 20 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS