1

SERUM CANCER ANTIGEN 125(CA125) IN THREATENED

MISCARRIAGE AND NORMAL PREGNANCY.

A DISSERTATION SUBMITTED TO THE

NATIONAL POST GRADUATE MEDICAL COLLEGE OF

NIGERIA

IN PART FULFILLMENT OF THE REQUIREMENTS

FOR THE

FELLOWSHIP OF THE COLLEGE

FMCOG PART II EXAMINATION

BY

DR (MRS) ADEKU MOSUNMOLA ABAKE

M.B.B.S LAGOS

MAY 2013

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3

TABLE OF CONTENTS

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CONTENT PAGE

Cover page i

Attestation ii

Certification iii

Content Iv

Abstract v

INTRODUCTION 1

RELEVANCE OF THE STUDY 3

LITERATURE REVIEW 4

OBJECTIVES 9

METHODOLOGY 10

RESULTS 16

DISCUSSION 18

TABLES 21

REFERENCES 25

APPENDIX 31

WORK PLAN 34

ETHICAL CLEARANCE 35

ABSTRACT

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Background:

Spontaneous miscarriage is a common early pregnancy complication, often times, a

significant cause of psychological and emotional burden to patients. To the best of my

knowledge, there is paucity of studies on prediction of pregnancy outcome in patients

with threatened miscarriages in Nigeria. This study compared levels of maternal serum

CA125 in pregnancies with threatened miscarriages and that of normal intrauterine

pregnancy between gestational ages 6 weeks and 19weeks + 6 days.

Methodology:

Sixty-five women with threatened miscarriage (cases) and 65 women with normal on-

going intrauterine pregnancies (controls) were studied. Whole blood samples were

collected at presentation for estimation of CA125 by the enzyme linked immunosorbent

assay (ELISA) technique. Ultrasound scan confirmation of fetal heart activity was also

done and the cases were treated appropriately. Statistical analysis was done using

SPSS version 17 software package.

Results:

The age range of all participants was 20 to 40 years, with mean value of 30.5 ± 0.38

years. The mean maternal age for cases was 29.5± 0.14 years and 30.1±0.14 years

for controls. Mean parity for cases was 1.1 ± 0.08 and 0.91 ± 0.08 for controls. The

mean gestational age for cases was 10.3 ± 0.65 weeks and for controls, it was 12.1 ±

0.65 weeks. There was no statistically significant difference between maternal age,

parity and gestational age between cases and controls. The mean serum CA125 among

cases was 30.1±1.1iu/ml and 22.9±1.2 iu/ml among the controls. This was found to

be statistically significant, p value 0.0001. Serum CA125 level among final aborters

(cases who finally aborted) was also found to be higher than in non aborters (cases

who carried pregnancy to term) with levels of 34.8 ±1.4 iu/ml and 27.3± 1.2iu/ml

respectively. This was also found to be statistically significant with p value 0.001.

Further analysis using CA125 concentration of >36.2iu/ml (mean value of CA125 in

aborters + 1 S.D) as a threshold for intrauterine pregnancies that eventually got

aborted showed a sensitivity of 66.7%, specificity of 83.3%, positive predictive value

of 55.6% and negative predictive value of 88.9%.

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Conclusion:

The measurement of CA125 is a useful predictor of pregnancy outcome in threatened

miscarriages. From this study, it can be deduced that serum CA125 has a diagnostic

potential for predicting women with symptoms of threatened miscarriage who will

eventually miscarry. However, larger studies are recommended to give a universally

acceptable cut off value for serum CA125 and also to assess its routine use in the

prediction of pregnancy outcome in women with threatened miscarriage.

CHAPTER ONE

1.1 INTRODUCTION

Miscarriage can be simply defined as the loss of a pregnancy at a stage when the

embryo or fetus, is incapable of surviving independently, that is, before the age of

fetal viability.1 In the West African sub-region, fetal viability has been pegged at 28

weeks from the last menstrual period.2 Miscarriage is one of the most common early

pregnancy complications even in otherwise healthy women and it constitutes a

significant cause of emotional burden to the expectant mothers.3 Although the exact

incidence of spontaneous miscarriage is unknown because quite a number of

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miscarriages occur even before the woman realises she is pregnant, it is estimated that

as many as 12–15% of clinically recognized pregnancies, and as many as 17%-22% of

all pregnancies, result in spontaneous miscarriage.4,5 There is paucity of data on

incidence of spontaneous miscarriage in the Nigerian population.

CA-125 (cancer antigen 125 or carbohydrate antigen 125) also known as mucin 16 or

MUC16 is a member of the mucin family glycoproteins with a high molecular weight

ranging between 200 to 2000 kilo-Dalton.6 It is expressed in normal human tissue such

as coelomic epithelium, amnion and derivatives and the fetal serous surfaces

(pericardium, pleura and peritoneum).7 It is also histo-chemically detectable in

the epithelium of the endocervix, endometrium (endometrial glands) and fallopian

tubes and also on the serous surface of the female genital apparatus.7 Therefore, a

basal serum CA-125 level exists in humans and is due to the secretary function of

these organs.7

In normal pregnancy, levels of CA125 rises modestly in the first trimester and then

drops during the second and third trimester to the range found in the non-pregnant

women.8 In cases of threatened miscarriage, studies of maternal serum levels of CA125

has been inconclusive. While several studies have actually demonstrated significant

elevation in first trimester serum CA125 levels among patients with threatened

miscarriage compared with matched counterparts with normal on-going

pregnancy9,10,11, others have shown no such association.12

This study is therefore designed to compare levels of maternal serum CA 125 in

pregnancies with threatened miscarriages and those of normal pregnancies between

gestational ages of 6 weeks and 19 weeks + 6 days, in the Nigerian population and to

determine if CA125 levels can be used to prognosticate outcome of the pregnancy.

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1.2 RELEVANCE OF STUDY TO OBSTETRICS AND GYNAECOLOGY

Miscarriage is one of the most common early pregnancy complications and it

constitutes a significant cause of psychological and emotional distress to both the

patient and attending physician.3 With the increase in infertility rate noted in our

environment, pregnancy loss has taken on a particular significance in a woman’s life

and has become an important social problem. Although a woman physically recovers

from a miscarriage quickly, psychological recovery for parents in general can take a

long time. People differ greatly in this regard, some are able to move on after a few

months, but others take more than a year. In a questionnaire study, about half (55%)

9

of the miscarrying women presented with significant psychological distress

immediately, 25% at 3 months; 18% at 6 months, and 11% at 1 year after

miscarriage.13 For those who do go through a process of grief, it is often as if a baby

had been born but died since bonding with the fetus in-utero had commenced as soon

as the pregnancy was diagnosed.

In view of this, biochemical studies to prognosticate pregnancy outcome in cases of

threatened miscarriage will be highly relevant in counselling and relieving anxiety in

affected patients. While some studies have shown that CA125 levels can be used to

prognosticate outcome in cases of threatened miscarriage especially in combination

with other hormones like beta-HCG,9,14 others have shown that it is not predictive of

outcome of the pregnancy.38

This study is therefore designed to compare levels of maternal serum CA 125 in

pregnancies with threatened miscarriages and those of normal pregnancies between

gestational age of 6 weeks and 19 weeks + 6 days in the Nigerian population and to

determine if CA125 levels can be used to prognosticate outcome of the pregnancy.

CHAPTER TWO

LITERATURE REVIEW

2.1 DEFINITION

Abortion refers to any process by which a pregnancy ends with the death of the fetus

before the age of viability. This can either be spontaneous or induced. Many women

who have had spontaneous miscarriages, however, object to the term "abortion" as it

is generally associated with induced abortions. In recent years there has been

discussion in the medical community about avoiding the use of this term in favour of

the less ambiguous term "miscarriage".15

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2.2 PREVALENCE, RISK FACTORS AND AETIOLOGY

Miscarriage is one of the most common complications of early pregnancy3 and most

clinically apparent miscarriages (66-80% in various studies) occur during the first

trimester16. The true incidence of spontaneous miscarriage is unknown but it has been

estimated to complicate as many as 12–15% of clinically recognized pregnancies, and

as many as 17%-22% of all pregnancies.4,5 Risk factors for spontaneous miscarriage

include advanced maternal age, multiple fetus pregnancies, uncontrolled diabetes

mellitus, polycystic ovarian syndrome, cocaine, tobacco and other hard drug use in

pregnancy, excessive alcohol intake, poor nutrition, use of antidepressants in

pregnancy, previous history of miscarriage, exposure to environmental toxins and

assisted reproductive technology.17-21 Causes of miscarriage include chromosomal

abnormalities (commonest cause in the first trimester), genetic, uterine, hormonal

abnormalities, viral infections, immunological disorders and other unknown causes.4,5

2.3 TYPES OF MISCARRIAGE

Miscarriage can be threatened, inevitable, incomplete, complete, missed, septic or

recurrent/ habitual miscarriages. Threatened miscarriage is bleeding of intrauterine

origin before age of viability, with minimal or no associated abdominal pain, without

cervical dilatation or effacement and without expulsion of products of conception;

inevitable miscarriage refers to bleeding of intrauterine origin with associated

abdominal pain, dilatation of the cervix or drainage of liquor; complete is expulsion of

all products of conception, incomplete refers to expulsion of some, but not all of the

products of conception, missed abortion implies that the fetus is dead but still remains

in utero with no signs of imminent expulsion while in septic abortion, the uterus and

sometimes the surrounding structures are infected. Recurrent miscarriage is the

occurrence of three or more consecutive miscarriages.22

2.4 NATURAL HISTORY OF MISCARRIAGES

Although vaginal bleeding is a common occurrence in early pregnancy, complicating

about 25% of pregnancies, about 50% of affected cases will proceed to have a viable

term pregnancy.23 Threatened miscarriage presents commonly with vaginal bleeding,

which may be associated with mild abdominal pain.23 At present, the diagnosis of

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threatened miscarriage is essentially clinical and ultrasonographic.23,24 Sonography can

usually differentiate threatened miscarriage from other causes of bleeding in

pregnancy, which include ectopic gestation, molar pregnancy, or an inevitable

abortion. Sonogragraphic findings in cases of threatened miscarriage includes presence

of a normal gestational sac with or without an embryo, depending on the age of the

pregnancy.25 Fetal heart activity should be visible with transvaginal sonography once

the fetal pole is at least 5 mm long.26 Demonstration of fetal heart activity is generally

associated with a successful pregnancy rate of 85-97%.27,28,29,30 Several studies have

reported a loss rate of 3.4-5.5% if bleeding occurs after fetal heart activity starts,28,29

and infact, identification of fetal heart activity by ultrasound carries a 97% likelihood

for the pregnancy continuing beyond 20 weeks.30 In late first trimester threatened

miscarriages, evidence of subchorionic haemorrhage may be seen.31 This is bleeding

resulting in marginal abruption with separation of the chorion from the endometrial

lining. This may be seen as hyperechoic or hypoechoic areas on ultrasonography,

depending on age of the blood product at time of scanning. The prognostic value of a

subchorionic haematoma in ultrasound has been disputed. Although a large separation

has been associated with about a threefold increased risk of miscarriage in women

with bleeding31 the presence or the size of haematoma did not affect miscarriage rates

in other prospective studies.32,33

2.5 ROLE OF BIOCHEMICAL MARKERS IN MISCARRIAGES

Vaginal bleeding occurring in early pregnancy is associated with a high risk of

spontaneous miscarriage. About 10-20% of affected pregnancies are lost even in the

presence of a demonstrable fetal heart.34 Occasionally, this bleeding may persist for

weeks and then, it becomes essential to decide whether there is any possibility of

continuation of the pregnancy or not. Several biochemical markers have been

evaluated whether singly or in combination to predict pregnancy outcome in such

instances. These markers include beta human chorionic gonadotrophin (b-HCG),

progesterone, inhibin-A, pregnancy associated plasma protein A and carcinoma antigen

125 (CA125). Results from these studies have however been inconclusive.14,35,36,37,38

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2.5.1 CA125 LEVELS IN PREGNANCY

The cancer antigen CA 125, initially detected by Bast et al in 1981 by using monoclonal

antibodies raised against cells derived from the ovarian cancer cell line OVLA 433.6,39

CA125 is best known as a marker for ovarian cancer40, but it may also be elevated in

other cancers, including those originating in the endometrium, fallopian tubes, lungs,

breast and gastrointestinal tract.41 CA-125 may also be elevated in a number of

relatively benign genital conditions, such as endometriosis,42 adenomyoma, uterine

leiomyoma, several diseases of the ovary, pregnancy,43 pelvic inflammatory diseases

and inflammatory conditions in the abdominal area, both cancerous and benign.

Nongenital causes include hepatic diseases, peritonitis, renal failure, breast, colon and

lung cancer, and tuberculosis. Thus, besides being utilized for clinical follow up of

ovarian tumors, CA-125 is also a valuable marker for other gynecological diseases. It

has been suggested that the availability of readily accessible and relatively cheaper

assays may help to provide a much wider field of clinical use for CA-125 measurements

in the near future.44

Several studies have looked at levels of CA125 in pregnancy. During the first trimester

of pregnancy, the maternal serum levels of CA 125 rises modestly, then drops during

the second and third trimesters to the range found in nonpregnant women,8,45 and

then rises again in the immediate post partum period.11 A systematic review by Hans et

al which looked at 6 gynaecologic tumour markers in pregnancy also showed that

during normal pregnancy, maternal serum CA125 is elevated especially in the first

trimester, with maximum values of 55Oiu/ml.46 The rise in CA125 levels in the first

trimester and immediate post partum period is thought to be due to the disruption of

the tropho-decidual interface during the period of implantation in the first trimester

and during placental seperation in the post partum period respectively, causing an

increased release of this biomarker from the tropho-decidual interface. Serum CA125

is also found to be present in high concentrations in human amniotic fluid47 compared

with maternal or fetal blood.45 Extracts of human decidua and chorion have also been

found to contain significant quantities of CA125.45 Whether the source of CA 125 is

fetal membranes or decidua, the antigen seems to be distributed preferentially within

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the amniotic fluid and excluded from the maternal vascular compartment.45 Recently,

studies have however explained that decidual CA 125 gains access to the maternal

compartment via a “tubal reflux,” resulting in subsequent absorption into maternal

circulation, via the peritoneal lymphatics.45

2.5.2 CA125 AND THREATENED MISCARRIAGES

At present, the function of CA125 in pregnancy is poorly understood and its clinical

significance in patients with threatened miscarriage is still controversial.10,48 During

threatened miscarriage, the disruption of the tropho-decidual layer is thought to cause

an increased release of CA125 from that interface, manifesting as an abnormal

elevation in the maternal serum.

Several studies have shown significantly elevated levels of CA125 in patients with

threatened miscarriage when compared with normal ongoing intrauterine

pregnancy.9,11,14,38,49,50,51 While some studies have shown that levels of CA125 can be

used to prognosticate outcome of pregnancies complicated with threatened

miscarriage,9,14,49 other studies disagree with this finding.12,52,53 A meta-analysis by

Katsikis et al have also shown that measurement of progesterone and CA125 levels is

useful in discriminating ectopic and intrauterine abortive from normal pregnancies.54

Currently, no universally accepted cut-off vale of CA125 for prognosticating pregnancy

outcome exists, therefore different cut-off values have been used in different studies.

2.6 MANAGEMENT

There is currently, no clear-cut treatment for threatened miscarriage.55 Physicians have

traditionally prescribed bed rest but this is unlikely to be effective since the aetiology of

most miscarriages is not related to an excess of activity. Currently, there is insufficient

evidence of high quality to support a policy of bed rest in order to prevent miscarriage

in women with fetal viability and vaginal bleeding in the first half of pregnancy.56

Hormones such as progestogens and beta-(HCG) have also been used in studies but

there is still no current evidence to support the routine use of these hormones in the

treatment of threatened miscarriages.57,58

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CHAPTER THREE

3.1 STATEMENT OF OBJECTIVES

3.1.1 AIM

To determine if serum CA125 is a useful predictor of pregnancy outcome in women

with threatened miscarriages.

3.1.2 OBJECTIVES

1. To compare serum levels of CA125 in threatened miscarriages and normal on-

going pregnancies at gestational age between 6 weeks and 19 weeks+6 days.

2. To assess if serum CA125 can be used to prognosticate outcome of pregnancy,

in pregnancies complicated with threatened miscarriage

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3.2 THE HYPOTHESIS

1. Serum CA125 is higher in threatened miscarriages compared with normal

pregnancy

2. Serum CA125 levels can be used to prognosticate outcome of pregnancy, in

pregnancies with threatened miscarriage.

CHAPTER FOUR

METHODOLOGY

4.1 STUDY DESIGN

This research work was a case control study.

4.2 SETTING

This study was conducted at the Lagos University Teaching Hospital (LUTH), Lagos,

Nigeria. Participants were recruited from the gynaecological emergency department

and antenatal clinics in this institution. LUTH is a tertiary institution located in mainland

Lagos, and serves as a referral centre for other hospitals in both the public and private

sectors in Lagos.

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The antenatal clinics run between the hours of 8am and 2pm, Mondays through

Fridays, with the exception of Wednesdays while the gynaecological emergency is

always constantly opened to patients.

4.3 STUDY POPULATION

The participants were pregnant women attending the LUTH antenatal clinic or

presenting at the accident and emergency gynaecology section, who met the inclusion

criteria.

4.3.1 INCLUSION CRITERIA

1. All booked and unbooked antenatal patients with gestational age between 6weeks

and 19weeks +6 days, with normal pregnancy.

2. All booked and unbooked antenatal patients with gestational age between 6 weeks

and 19 weeks+ 6 days, with threatened miscarriage (bleeding per vaginam with a

closed cervical os).

3. Pregnant women with ultrasound scan confirmed fetal viability.

4. Pregnant women who gave informed written consent

4.3.2 EXCLUSION CRITERIA

1. Pregnant women with ultrasound scan diagnosed fetal non-viability.

2. Pregnancies with multi- fetal gestation.

3. Pregnant women with previous history of delivery of chromosomally abnormal

babies.

4. Pregnancies from in-vitro fertilization

5. Extra-uterine pregnancies

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6.Pregnant women with history of leiomyoma, endometriosis, tuberculosis, hepatic

diseases, renal failure or history of breast, lung, colon, ovarian or endometrial cancers

co-existing with pregnancy.

8. Pregnant women who failed to give informed written consent.

4.4 DATA COLLECTION

4.4.1 CASE DEFINITION

The cases were booked and unbooked pregnant women that presented in LUTH

antenatal clinic or gynaecology emergency unit, at gestational age between 6 weeks

and 19 weeks + 6 days, who met the criteria for threatened miscarriage (bleeding per

vaginam with a closed cervix), with ultrasound confirmed fetal viability and also fulfil

the inclusion criteria.

4.4.2 DEFINITION OF CONTROL

For every case, a control was recruited from the same study population. Controls were

booked or unbooked consecutive consenting age, parity and gestational age matched

pregnant women at gestational age between 6 weeks and 19 weeks + 6 days, with

normal on-going pregnancy, who also met the inclusion criteria for the study.

4.4.3 EVALUATION OF CASES AND CONTROL

The purpose of the study was explained to the participants and written informed

consent was obtained. Using a proforma, the socio-demographic data, parity,

gestational age estimated from the last menstrual period or from a first trimester

dating scan, past medical history to exclude benign conditions like leiomyoma,

endometriosis, tuberculosis, hepatic or renal diseases, history of lung, breast, colon,

ovarian or endometrial cancers coexisting with pregnancy. Maternal social class

stratification was categorised from class I to class V, using their occupation which was

stratified as professional, skilled, semi-skilled, unskilled workers and housewife, that is,

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the national readership survey (NRS) classification. Also, a detailed review of the

antenatal records was done, patients were examined and treated appropriately.

4.4.4 COLLECTION OF SAMPLES

I adequately counselled the participants about the study and obtained informed written

consent. Thereafter, 4 millilitres of a peripheral venous blood sample was obtained

from the participants and transported to the laboratory in plain bottles. Cases were

labelled with their initials and coded A (odd numbers) while controls were labelled with

their initials and coded A (even numbers). The identity and distinction between the

cases and controls were not be revealed to the laboratory scientists until all the

samples had been processed. The participants were then followed up till delivery to

determine the pregnancy outcome. Individual participants were followed up to the

postnatal visit where the individual reports were discussed with them.

4.5 LABORATORY METHODS

The assay was carried out in conjunction with a senior laboratory scientist at the

prenatal laboratory, LUTH. Samples were obtained by venupuncture, 4 mls of blood

was collected into plain bottles, centrifuged to extract serum for estimation of CA125.

Samples were stored at -200C until sample size was completed and ready for analysis.

Estimation of serum CA125 levels was determined using the solid phase sandwich

enzyme linked immunosorbent assay (ELISA) by DRG CA125 EIA 3939, DRG

International, Inc USA. The micro-titre plates were already pre-coated with monoclonal

antibodies specific to CA125. 50IU of freshly diluted enzyme conjugate and 50uL of

standard, control or sample was added to the appropriate wells, thoroughly mixed for

10 seconds, incubated at room temperature for 30 minutes without covering the plate,

the contents of the well were briskly shaken out and the wells washed 3 times with

diluted wash solutions (400IU per well). The wells were then blot dried. Next 100lU of

substrate solution was added to each well, incubated at room temperature for 30

minutes, then 100lU of stop solution was added to each well. The colour change was

then measured photo-spectrometrically at wavelength of 450 nm, within 10 minutes of

adding the stop solution.

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4.6 DETERMINATION OF SAMPLE SIZE

The sample size was calculated using the formula59 and values from previous study9:

N = (U+V)2 (S12 + S2

2) ; S = S.E.M X √n

(M1-M2)2

where:

N =Desired Sample size

U= Power of 95%, u=1.28

V= Level of significance of 5%, v=1.96

S1=Standard deviation of cases=19.23

S2=Standard deviation of controls=22.98

M1=Mean of cases=37.44

M2=Mean of controls=26.20

Therefore, N = (1.28+1.96)2 X (19.232 + 22.982)

(37.44 – 26.20)2

N = 7.84 x (369.8 + 528.1)

(11.24)2

N = 7.84 x 897.9

126.3

N= 7039.5

126.3 N= 55.7

With 10% attrition rate of 5.57, N = 55.7 + 5.57 = 61.27

approximately 65 cases and 65 controls will be used for the study.

4.7 STATISTICAL ANALYSIS

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The data obtained was collected and analyzed using statistical package for social

sciences (SPSS version 17). Frequency and percentages were generated and the

means and standard deviation were derived. The student t test and chi-square were

used for analysis where appropriate. A p value of <0.05 was considered significant.

Test performance evaluation of the observed cut off value for CA125 in this study was

obtained using the formular: Sensitivity = True positive/ true positive + false negative;

specificity = true negative/ true negative + false positive; positive predictive value =

true positive/ true positive + false positive, negative predictive value = true negative/

false negative + true negative and diagnostic accuracy = true positive + true negative/

true positive + true negative + false positive + false negative.

4.8 ETHICAL CONSIDERATIONS

The study was carried out after obtaining approval from the Health Research Ethics

Commitee of the Lagos University Teaching Hospital.

The purpose of the study was explained to the participants and informed consent was

obtained prior to data and sample collection. The women were informed of their

freedom to withdraw or refuse to take part in the study without prejudice to their

usually expected standard of care.

Confidentiality of data obtained was strictly ensured and the laboratory test was

carried out at no cost to the patient. Precautions were put in place to ensure there was

minimal discomfort or inconveniences to the patient, as a result of the study.

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RESULTS

One hundred and thirty (130) pregnant women were enrolled in the study, 65 (50%)

of them had threatened miscarriage (cases) while the remaining 65 (50%) had normal

on-going pregnancy (controls). The participants were all Nigerians, 54 (41.5%) of

them were unbooked {out of which 39 (72.2%) were cases and 15 (27.8%) were

controls} while 76 (58.5%) of them were booked {26, (34.2%) were cases and 50

(65.8%) were controls}. The mean age of all participants was 30.5 ± 0.38 years

(range 20-40 years); mean parity was 0.94 ± 0.09 (range 0-4) and majority, 70

(53.8%) were of the Yoruba tribe. Ninety-one (70%) of them were Christians and 117

(90%) were married. The mean gestational age at sampling for all participants was

11.2 ± 0.65 weeks {mean gestational age for cases was 10.3 ±0.65 weeks and for

controls, it was 12.1 ± 0.65 weeks}, 102 (78%) of participants were in the first

trimester while the remaining 28 (22%) of them were in the early second trimester

(<20 weeks) as shown in table 1.

As further illustrated in table 1, the mean maternal age among cases was 29.5± 0.14

years while the mean maternal age for the control (normal on-going pregnancy group)

was 30.1 ± 0.14 years. The mean parity for cases was 1.1 ± 0.08 and 0.91 ± 0.08 for

controls. Fifty-five (84.6% of cases) were in the first trimester while 47 (72.3% of

controls) were in the first trimester. The mean gestational age at blood sampling

among the cases was 10.3± 0.65 weeks while it was 12.1 ± 0.65 weeks for the

controls. There was no statistically significant difference between maternal age, parity

and gestational age at sampling between the cases and controls.

The mean concentration of serum CA 125 among cases was 30.1 ± 1.1 iu/ml while the

mean concentration among controls was 22.9 ± 1.2 iu/ml. This was statistically

significant with p value of 0.0001, as shown in table 2.

Table 3 shows the comparison of mean CA125 level in threatened abortion group in

relation to continuity of pregnancy. Out of the 65 cases of threatened miscarriage, 2

(3.1%) of the participants were lost to follow up and pregnancy outcome was

unknown. Forty-eight (73.8%) carried their pregnancy to term while 15 (23.1%) had

their pregnancies terminated before 20 weeks of gestation. The mean serum CA125

22

level in patients whose pregnancies were aborted (aborters) was 34.8 ± 1.4 iu/ml

while the mean among those whose pregnancies continued till term (non-aborters)

was 27.3 ± 1.2iu/ml. This was found to be statistically significant with p value of

0.001. The gestational age during which abortion occured among aborters ranged

between 7 weeks to 15 weeks with a mean of 8.3± 1.8 weeks.

Using a threshold value (cut off value) of 36.2iu/ml (that is mean serum CA125 among

aborters + 1 SD) for eventual miscarriage, a sensitivity of 66.7%, specificity of 83.3%,

positive predictive value of 55.6% and negative predictive value of 88.9% was

obtained and the diagnostic accuracy was 79.4% as shown in table 4. This implies that

approximately 67 out of 100 women with threatened miscarriage, who have CA125

levels > than 36iu/ml will finally abort, approximately 83 out of 100 women with

threatened miscarriage with CA125 <36.2iu/ml will not progress to abort.

23

DISCUSSION

Miscarriage occurs in about 15% of all spontaneous pregnancies4,5 and is a traumatic

event for the woman and the attending physician. Several studies have been carried

out to assess the clinical value of some markers in reproductive failure. Progesterone,

estradiol, relaxin, Schwangerschaft protein, lipoperoxides and others have been

evaluated by many authors as predictors of pregnancy outcome but only serial

determination of hCG has gained general consent to date. The observation of an

increase in CA 125 in early spontaneous or induced miscarriage has suggested the

possible use of this marker in evaluating pregnancy outcome.

This study was conducted in a homogenous group of pregnant women who presented

in LUTH at gestational age of between 6 weeks and 19weeks + 6 days as calculated

from their last menstrual period and confirmed by ultrasound scan. Sixty-five (50%) of

the participants had threatened miscarriage (in the presence of ultrasonographically

confirmed viable fetus) while the remaining 65 (50%) of the participants had normal

on-going pregnancy. Maternal age, parity and gestational age were matched between

cases and controls and these showed no statistically significant difference.

In this study, the mean CA125 level in cases was significantly higher than in controls.

This high level reflects a probable trophodecidual origin for CA125. This study also

showed that the higher level of serum CA125 seen in aborters compared with the non-

aborters was statistically signicant. This finding is similar to previous studies by

Sedigheh et al,9 Scarpellini et al,14 and Fiegler et al.49 In the study by Sedigheh et al,9

the mean serum concentration of CA125 in cases with threatened miscarriage was

37.44 ± 2.72iu/ml while it was 26.2 ± 3.25iu/ml in normal ongoing pregnancies. Also

the mean concentration of CA125 in finally aborted cases was 58.17 ±7.25iu/ml and

30.89 ±2.78iu/ml in those threatened abortions whose pregnancies continued. These

were all found to be statistically significant, as also seen in this study. Some studies

however do not agree with this findings. Hornstein et al12 showed in their study that

there is no significant difference between levels of CA125 between cases of threatened

miscarriages and normal intrauterine pregnancy This difference may be due to the fact

24

that the patients used in their study were all seen in fertility units with history of

infertility or habitual abortions. It may be possible that such a population may differ

from a normal fertile population (used in this study) with respect to CA125 level. The

study in Iraq by Mahdi et al52 also showed that CA125 levels in threatened miscarriage

was higher than normal intrauterine pregnancy but this finding was found to be

statistically insignificant. This may also be due to differences in the assay method for

CA125 measurement. Radioimmunoassay was used in their study while Enzyme linked

immunosorbent assay was used in this study.

Several studies have used different cut off values for prognosticating outcome of

threatened miscarriage with serum CA125. In this study, when a threshold of 36.2iu/ml

was used for occurrence of miscarriage, the sensitivity was 66.75%, specificity 83.3%,

positive predictive value 55.6% and negative predictive value of 88.9%. This is also

similar to some previous reports. Katsikis et al in their meta-analysis showed that

serum levels of >41.9u/ml is associated with increased risk of intrauterine abortive

pregnancy with sensitivity of 80%, specificity of 87%, positive predictive value of 66%

and negative predictive value of 93%.60 Spitzer et al also showed that all women with

symptoms of threatened miscarriage who have a CA125 level ≥ 35iu/ml should be

considered to be at a greater risk of miscarriage.11 Fiegler et al 49 used a cut off value

of 43iu/ml in their study.

The study by Schmidt et al showed that though a single serum measurement of CA125

in symptomtic first trimester pregnant patients failed to discriminate between

spontaneous miscarriage, ectopic or normal pregnancy, the sequential determination of

CA125 measurement (using cut off of 65iu/ml and 60 iu/ml in the first and second

measurements respectively) appear to be a highly sensitive prognostic marker in

patients with viable pregnancy at risk of miscarriage38 while Fiegler et al found that a

single serum CA125 level determination is valuable in predicting pregnancy outcome in

women with imminent abortion presenting with abdominal pain, vaginal bleeding or

both.49 Another report also showed that all patients who eventually aborted had CA125

values more than 125iu/ml while the controls had a value not more than 93iu/ml.50,61

25

CONCLUSION

This study has shown that serum CA125 has a diagnostic potential for miscarriages in

cases of threatened intrauterine pregnancy. This study has demonstrated significantly

elevated levels of serum CA125 in women with symptoms of threatened miscarriage

compared with normal on- going pregnancy. Larger studies are however required to be

able to fix a universally accepted cut-off value for this cheap and readily available

marker in the prediction of pregnancy outcome in cases of threatened miscarriage.

LIMITATIONS OF THE STUDY

1. Some patients may have some clinical conditions in the exclusion criteria but

may not be aware of it or may not offer the information.

RECOMMENDATION

Based on findings in this study, maternal levels of serum CA125 >36.2iu/ml in women

with symptoms of threatened miscarriage is associated with a greater risk of

miscarriage. Further larger controlled studies are however needed to arrive at a

universally acceptable cut off value for this marker in pregnancy.

26

Table 1. Sociodemographic and obstetric characteristics of pregnant women

with and without threatened miscarriage, enrolled in the study.

Parameter Subject N = 130(100%) T χ2 P

Threatened

miscarriage(cases)

Control

Maternal Age, (years) Median (range) Mean + SEM Age group 20 -24 25-29 30-34 ≥ 35 Ethnic group Yoruba Ibo Hausa Others Religion Christianity Islam Marital status Married Single Divorced Occupation Professional Skilled Semiskilled Unskilled Housewife Booking status Booked Unbooked

30.1 (20 – 40) 29.5 + 0.14 10(15.4%) 39(60%) 11(16.9%) 5(7.7%) 38(58.5%) 23(35.4%) 3(4.6%) 1(1.5%) 44(67.4%) 21(32.3%) 59(90.8%) 4(6.2%) 2(3.0%) 4 (6.2%) 15(23.05) 25(38.5%) 12(18.5%) 9(13.8%) 26(40.0%) 39(60.0%)

30.6 (22 – 40) 30.1 + 0.14 13(20%) 37(56.9%) 12(18.5%) 3(4.6) 32(49.2%) 18(27.7%) 10(15.4%) 5(7.7%) 47(72.3%) 18(27.7%) 58(89.35%) 2(3.0%) 5(7.7%) 5(7.7%) 11(16.9%) 23(35.4%) 21(32.3%) 5(7.7%) 50(76.9%) 15(23.1%)

0.75

- 1.11 0.62 0.02 0.82 0.99 0.07

0.53 0.46 0.78 0.89 0.87 0.85 0.61 0.79

27

Parity Mean + SEM Median (range) Parity Group 0 1 2 3 4 Gestational age, (weeks) Mean + SEM Gestational age group 6 – 13 13 - <20

1.1± 0.08 1 (0 – 4) 14(21.5%) 19(29.2%) 8(12.3%) 15(23.1%) 9(13.9%) 10.3 ± 0.65 55(84.6%) 10(15.4%)

0.91± 0.08 1 (0 – 4) 16(24.6%) 16(24.6%) 12918.5%) 13(20.0%) 8(12.3%) 12.1 ± 0.65 47(72.3%) 18(27.3%)

0.51 0.63

3.3 0.02

0.61 0.5 0.43 0.88

Data are expressed as mean, median, range of values and numbers (percentages).

Disparity between mean and median values was evaluated by Student’s t-test, while χ2

was used to compare percentages.

28

Table 2. Serum ca125 levels between participants with threatened abortion

and the control

Parameter Participant T test P value

Threatened Abortion Control

Ca125 30.1 + 1.1 22.9 + 1.2 3.97 0.0001

Table 3. Serum ca125 levels between aborters and non-aborters.

Parameter iu/ml Participant T test P value

Aborters (15) Non-aborters (48)

Mean serum Ca125 34.8 + 1.4 27.3 + 1.2 3.31 0.001

29

Table 4:

Test Miscarriage

Ca 125 >36.2

iu/ml

Present Absent Total

Positive 10 8 18

Negative 5 40 45

Total 15 48

Sensitivity = 66.7%

Specificity = 83.3%

Positive predictive value = 55.6%

Negative predictive value = 88.9%

30

REFERENCES

1. Lathi R.B First trimester miscarriage evaluation. Semin Reprod. Med 2011; 29

(6): 463-469.

2. Morhsee R.A.S, Morhee E.S.K. Overview of the law and the availability of

abortion services in Ghana. Ghana Med J 2006; 40(3): 80-86.

3. Gracia C.R, Sammuel M.D. Risk factors for spontaneous abortion in early

symptomatic first trimester of pregnancy. Obstet Gynaecol 2005; 106(5): 993-

999.

4. Zinatman M.J, Clerg E.D, Brown C.C, O’Connor J, Selevan S.G Estimates of

human fertility and pregnancy loss. Fertil Steril 1996; 65: 503-509.

5. Ellish N.J, Saboda K, O’Connor J, Nasca P.C, Stanek E.J, Boyle C. A prospective

study of early pregnancy loss. Hum Reprod 1996;11:406-412.

6. Yin B.W, Lloyd K.O. “Molecular cloning of the CA125 ovarian cancer antigen:

identification as a new mucin, MUC16” J. Biol Chem 2001, 276 (29): 27371-

27375.

7. Berek S.J “Novaks gynaecology” 13th Ed. Lippincott William and Wilkins 2002:

518.

8. Seki K, Kikuchi T, Kato K. Increasesd serum CA125 levels during first trimester

of pregnancy. Acta Obstet Gynaecol Scand 1986; 65: 583-585.

9. Sedigheh Ayaty, Fatemeh Vahid Roudsari, Fatemah Tavassoly. CA125 in normal

pregnancy and threatened abortion. Iranian J of reproductive medicine 2007;

5(2): 57-60.

10. Kobayashi F, Takashima E, Sagawa N. Maternal serum CA125 levels in early

intrauterine and tubal pregnancy. Arch Gynaecol Obstet 1993; 252(4): 185-189.

11. Spitzer M, Kaushai N, Benjamin F. Maternal CA125 levels in pregnancy and the

pueperium. J. Reprod Med. 1998; 43(4): 387-392.

12. Hornstein M.D, Check J.H, Hill J.A. Serum CA125 levels and spontaneous

abortion. Am. J Obstet Gyanecol 1995; 172(2) : 695-699.

13. Lok I.H, Yip A.S, Lee D.T, Sahota D, Chung T K. “ A 1yr longitudinal study of

psychological morbidity after miscarriage”. Fertil Steril 2010; 93(6): 1966-1975.

31

14. Scarpellini F, Mastrone M, Sabrasia M, Scarpellini L. Serum CA125 and beta HCG

in first trimester abortions. Intl J. Gynaecology ang Obstetrics 1995; 49: 259-

264.

15. Hutchon D, Cooper S. “Terminology for early pregnancy loss must be changed”.

BMJ 1998; 317 (7165): 1081.

16. Frances O ”Analysis of 1150 cases of abortion from the government RSRM lying

–in hospital, Madras”. J Obstet Gynaecol India 2008; 10(1): 62-70.

17. Heffnar L. Advanced maternal age- How old is too old? New England J. of Med

2004; 357(19): 1927-1929.

18. Jacobowics D.J, Iuorno M.J, Jacubowicz S, Roberts KA, Nestler JE. Effects of

metformin on early pregnancy loss in the polycystic ovary syndrome. J. Clin.

Endocrinol Metab 2006; 87(2): 524-529.

19. Ness R, Grisso J, Hirschinger N, Marcovia N, Shaw L, Day N, Kline J. “Cocaine

and tobacco use and the risk of spontaneous abortions. N. Engl. J Med 1999;

340(5): 333-339.

20. Broy P,Berard A. “Gestational exposure to anti-depressants and the risk of

spontaneous abortion: a review” Current drug delivery 2010; 7(1): 76-92.

21. Nakhai P.H.R, Broy P, Berard A. Use of antidepressant and risk of spontaneous

miscarriage. Canadian Med. Ass. J 2010; 182(110): 1031- 1035.

22. Lund M, Kamper-Jergensen M, Nielsen H.S, Lidegaard O, Andersen AM.

Prognosis for live birth in women with recurrent miscarriage: what is the best

measure of success? Obstet Gynaecol 2012; 119(1): 37-43.

23. Thilaganathan B. Evidence base for miscarriage diagnosis: better late than

never. Ultrasound Obstet Gynaecol 2011; 38(5): 487-488.

24. Bottomley c, Bourne T. Diagnosing miscarriage. Best Practise Res Clin Obstet

Gynaecol 2009; 23(4): 463-477.

25. Dighe M, Guevas C, Moshiri M, Dubinsky T, Dogras S. Sonography in first

trimester bleeding. J Clin USS 2008; 36(6): 352-366.

26. Falco P, Zagonaris S, Gabriella S,Berin M, Pilu G, Boricelli L. Sonography of

pregnancy with first trimester bleeding and a small intrauterine gestational sac

without a demonstrable embryo. Ultrasound Obstet Gynaecol 2003: 21:62-65.

32

27. Falco P, Milano V, Pilu G, David C, Grisolia G,Rizzo N, Bovicelli L. Sonography of

pregnancies with first trimester bleeding and a viable embyo: a study of

prognostic indicator by logistic regression analysis. Ultrasound Obstet Gynaecol

1996; 7:165-169.

28. Tongsong T, Srisomboon J, Wanapirak C, Sirichopirakul S, Pongsatha S,

Polsrisuthikul T. Pregnancy outcome of threatened abortion with demonstrable

fetal cardiac activity: a cohort study. J Obstet Gynaecol 1995; 21: 331-335.

29. Tannirandorn Y, Sangosawang S, Manotaya S, Uerparirojkit B, Samripradit P,

Charoenvidhya D. Fetal loss in threatened abortion after embryonal fetal heart

activity. Int’l J. Gynaecol Obstet 2003; 81:263-266.

30. Everett C.B, Preece E. Women with bleeding in the first 20 weeks of pregnancy.

Value of general practice ultrasound in detecting fetal heart movement. Br J Gen

Pract. 1996; 46: 7-9.

31. Bennett G.L, Bromley B, Lieberman E, Benacerraf B.R. Subchorionic

haemorrhage in first trimester of pregnancy: prediction of pregnancy outcome

with sonography. Radiology 1996; 200: 803-806.

32. Pedersen J.F, Mantoni M. Prevalence and significance of subchorionic

haemorrhage in threatened abortion. A sonographic study. Am J. Roentgenol

1990; 154:535-537.

33. Dickey R.P, Olar T.T, Cureola D.N, Taylor S.N, Matulich E.M. Relationship of first

trimester subchorionic bleeding detected by colour Doppler ultrasound to

subchorionic fluid, clinical bleeding and pregnancy outcome. Obstet Gynaecol

1992; 80: 415-420.

34. Jouppila P, Huhtaniemi J, Tapanainen J. Early pregnancy failure: study by

ultrasonic and hormonal methods. Obstet Gynaecol 1980; 55; 42-47.

35. Al-Sebai M.A, Diver M, Hipkin L.J. The role of a single free-hcg measurement in

the diagnosis of early pregnancy failure and prognosis of fetal viability. Hum.

Reprod 1996; 11: 881-888.

36. Al-Sebai M.A, Kingsland C.R, Diver M, Hipkin L, Mc Fayen I.R. The role of a

single progesterone measurement in the diagnosis of early pregnancy failure

and the prognosis of fetal viability. Br J Obstet Gynaecol 1995; 102: 364-369.

33

37. Flopio P, Luisi S, D’Antona D, Sereri F.M, Rago G, Petraglia F. Maternal serum

inhibin A levels may predict pregnancy outcome in women with threatened

abortion. Fertil Steril 2004; 81: 468-470.

38. Schmidt T, Rein D.T, Foth D, Eibach H.W Prognostic value of repeated serum

CA125 measurement in the first trimester of pregnancy. Eur. J Obstet Gynaecol

Reprod Biol 2001; 97: 168-173.

39. Bast R.C, Feeny M, Lazarus H, Wadler L.M, Colvin R.B, Knapp R.C. “Reactivity

of a monoclonal antibody with human ovarian carcinoma”. J Clin Invest 1998;

68(5): 1331-1337.

40. Osman N, O Leary N, Mulcahy E, Barrett N,Wallis F, Hickey K, Gupta R.

“Correlation of serum CA125 with stage, grade and survival of patients with

epithelial ovarian cancerat a single centre”. Ir Med J 2008: 101 (8): 245-247.

41. Bast R.C, Xu F.J, Yu Y.H, Barmill S, Zhang Z,Mills G.B. “CA125: The past and

the future” Intl J Biol Markers 1998; 13(4): 179-187.

42. Bagan P, Berna P, Assouad J, Hupertan V, Le Pimpec Barthes (Jan 2008).

“Value of cancer antigen 125 for the diagnosis of pleural endometriosis in

females with recurrent pneumothorax”. Eur Respir J 2008; 31(1): 140-142.

43. Sarandakou A, Protonotariou E, Rizos D. Tumour markers in biological fluids

associated with pregnancy. Crit Rev Clin Lab Sci. 2007; 44(2): 151-178.

44. Fiegler P, Kaminski P. Serum CA125 variability- new aspects of clinical

usefulness. Ginekol Pol 2003; 74(5): 412-418.

45. Quirk J.G, Brunson G.L, Long C.A, Bannon G.A, Sanders M.M CA125 in tissues

and amniotic fluid during pregnancy. Am J Obstet Gynaecol 1988; 159:644-649.

46. Sileny N H, Anouk Lotgerink, Mina M G, Kristel V C, Myrian H, Frederic A.

Physiologic variations of serum tumour markers in gynaecologic malignancies in

pregnancy: a systematic review. BMC Medicine 2012; 10(86): 1-10.

47. O’ Brien T.J, Hardin J.W, Bannon G.A, Sanders M.M CA125 antigen in human

samniotic fluid and fetal membrane. Am J Obstet Gynaecol 1986; 155: 50-55.

48. Witt B R, Wolf G C, Wainwright C J Relaxin, CA125, Progesterone, estradiol

Schwangerschaft protein and human chorionoic gonadotrophins are predictors

of outcome in threatened and non-threatened pregnancies. Fertil Steril 1990;

53: 1029-1035.

34

49. Fiegler P, Katz M, Kaminski K, Radol G. Clinical value of a single CA125 level in

women with symptoms of imminent abortion during the first trimester of

pregnancy. J Reprod Med 2003; 48(12): 982-988.

50. Ocer F, Bese T, Saridogan E, Aydinli K, Atasti T. The prognostic significance of

maternal serum CA125 measurement in threatened abortion. Eur J. Obstet

Gynaecol 1992; 46: 137-142.

51. Azogui G, Yarono V A, Zohar S CA125 is elevated in viable pregnancy destined

to be miscarried: a prospective longitudinal study. Fertil Steril 1996; 65: 1059-

1061.

52. Mahdi B M. Estimation of CA125 level in first trimester threatened abortion. The

internet J of Gynaecol and Obstet 2010; 12(2): 1

53. Vavilis D, Loufopoulos A, Karavida A, Zournatzi V, Bontis J N. Serum maternal

CA125 antigen levels in first trimester threatened abortion with demonstrable

fetal heart activity. J of middle East Fertility Society 2001; 6: 159-162.

54. Katsikis Z, Roussou D, Piouka A, Farmakiotis D, Kourtis A, Koiou Z V, Panidis D.

Diagnostic value of progesterone and CA125 in the prediction of ectopic and

abortive intrauterine pregnancy. Hippokratia 2005; 29(3): 124-129.

55. Alexandros Sotiriadis, Stephania Papatheodou, George Makrydimas. Threatened

miscarriage: Evaluation and management. BMJ 2004: 329(2): 152.

56. Alelan A, Althabe F, Belizan J, Bergel E. Bedrest during pregnancy for

preventing miscarriage. Cochrane Database Syst Rev 2005: 18(2): CD003576.

57. Devaseelan P, Fogarty P.P, Regan L. Human chorionic gonadotrophin for

threatened miscarriage. Cochrane Database Syst Rev2010; 12(5): CD007422.

58. Wahabi H.A, Abed Althagafi N.F, Elawad M, AL-Zeiden R.A. Progesterone for

treating threatened miscarriage. Cochrane Database Syst Rev 2011; 16(3):

CD005943.

59. Prabhaka G.N. Sample size, Biostatistics published by Jaypee brothers medical

publishers limited, 2006; 11: 110-119.

60. Katsikis Z, Roussou D, Panidin D. Receiver operator characteristic and diagnostic

value of progesterone and CA125 in the prediction of etopic pregnancy and

abortive intrauterine pregnancy. Eur J Obstet Gynaecol Reprod Biol 2006;

125(2): 226-232.

35

61. Check J H, Nowroozi K, Winkel C A. Serum CA125 levels in early pregnancy and

subsequent spontaneous abortion. Obstet Gynaecol 1990; 75: 742-744.

36

APPENDIX 1: PROFORMA

SERUM CANCER ANTIGEN 125(CA125) IN THREATENED MISCARRIAGE AND NORMAL

ON-GOING PREGNANCY.

Serial No.______ Hospital No--------------

SOCIODEMOGRAPHIC DATA

1. Initials of patient........................................................................................

2. Age............................................................................................................

3. Parity..........................................................................................................

4. Occupation..................................................................................................

5. Religion......................................................................................................

6. Marital status..............................................................................................

7. Booking status............................................................................................

8. Social class: I.............,II................,III...............,IV.............,V...............

INDEX PREGNANCY

1. LMP................, EDD................,EGA....................

2. Booking weight........................... Height........................

3. Bleeding per vaginam.........................................

4. Abdominal pain..................................................

5. Ultrasound scan findings...................................

SOCIAL HISTORY

1. Cigarette smoking.........................................................................

2. Drugs being used currently...........................................................

PAST MEDICAL HISTORY

1. History of chronic hypertension.......

2. History of diabetes mellitus.............

3. Other medical history (please specify) ..................

PAST OBSTETRIC HISTORY

1. History of previous miscarriage....................

37

PREGNANCY OUTCOME

1. a. Gestational age at delivery ..........................

b. Mode of delivery .........................................

c. If operative delivery, indicate reason ............

2. Pregnancy gets completely miscarried? .........................................

3. Gestational age at complete miscarriage ......................................

4. CA 125 level .........................................................

Participant’s phone number...................................................

Participant’s home address....................................................

38

APPENDIX 2: INFORMED CONSENT FORM

Informed consent form on: SERUM CANCER ANTIGEN 125(CA125) IN THREATENED

MISCARRIAGES AND NORMAL ON-GOING PREGNANCY.

I, ................................................................................. voluntarily consent to

participate in the above named research study conducted by Dr Mrs Adeku Mosunmola

A, of the Department of Obstetrics and Gynaecology, Lagos University Teaching

Hospital (LUTH), Idi-Araba, Lagos.

I have been given the following information:

1. That the research is undertaken to compare serum levels of CA125 in

threatened miscarriage and normal pregnancy.

2. That 4 millilitres of venous blood will be obtained from me at the time of

recruitment.

3. That my participation in this research will be at no cost to me or my family.

4. That I am not exposed to any risk from participating in this study

5. That the information generated from this study is for the purpose of research

only

6. That the information received from me will be treated as priviledged and

confidential.

7. That I have the right to ask questions on any aspect of this study that is not

clear to me before i participate.

8. That I am guaranteed the right to withdraw from the study at any time and this

will not affect the care I will receive at the hospital.

...........................................................

Signature/ thumbprint

Date

39

WORK PLAN

SERUM CA125 LEVELS IN THREATENED MISCARRIAGE AND NORMAL ON-GOING PREGNANCY.

YEAR 2012 YEAR 2013

S/N ACTIVITY Feb Mar Apr May Jun July Aug Sept Oct Nov Dec Jan Feb Mar Apr May

1 Proposal writing X

2 Ethical clearance X

3 Submission of proposal to

college for approval

X

4 Data collection and follow up X X X X X

5 Data analysis X

6 Review by supervisor and final

write up

X X

7 Submission of work to college X

8 Preparation for Part II FMCOG

exam

X X X X

9. Part II FMCOG exam x

40

41