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Defining Early pregnancy loss
Douglas Dumbrill
MRCOG FCOG
Life Vincent Pallotti and Groote Schuur Hospitals
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Pain and / or bleeding in early pregnancy
• viable intra- uterine pregnancy
• Failed or failing pregnancy
• Ectopic pregnancy
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Is there a chance of a viable pregnancy ?
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…. two clinical contexts
• Intrauterine pregnancy of unknown VIABILITY
• Pregnancy of unknown LOCATION
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0 1 2 3 4 5 6 7 8 9 10
Gestational age (weeks)
ovulation
implantation
βhCG > 25 iu/l
βhCG > 1000 iu/lgestational sac
Landmarks
Yolk sac CRL and fetal heart activity
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Four weeks gestation
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Gestational sac diameter
Grisolia et al, 1993
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Five weeks gestation
• ring-like structure
• echogenic rim
• eccentric
• visible by 5+2
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Yolk sac
• First visible 4+6 – 6+4
• Mean gestational sac diameter 5 – 12mm
• hCG up to 7000 iu/l
• Corresponds to secondary yolk sac embryologically
• Functions:
early haematopoesis
transport of nutritive substances to embryo
primordial germ cells
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Six weeks gestation
• Embryo first visible 5+4 – 6+4
• Mean gestational sac diameter 10 – 18mm
• Straight line adjacent to yolk sac, close to trophoblast
• Embryonic length 4 – 10mm
• Identified by cardiac activity
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Fetal heart rate
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Take care not to include the yolk sac
Six weeks gestation
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Seven weeks gestation
vitelline ductamnion
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0 1 2 3 4 5 6 7 8 9 10
Gestational age (weeks)
ovulation
implantation
βhCG > 25 iu/l
βhCG > 1000 iu/lgestational sac
Landmarks
Yolk sac
CRL 10 mm FH activity
CRL 15
CRL 21
CRL 30
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Mean Gestational sac diameter 21mm CRL 6.5 mm and no FH
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Mean Gestational sac diameter 21mm CRL 6.5 mm and no FH
• Non viable / Miscarriage
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Mean Gestational sac diameter 21mm CRL 6.5 mm and no FH
• Non viable / Miscarriage
• Too early
– would re scan
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Mean Gestational sac diameter 21mm CRL 6.5 mm and no FH
• Non viable / miscarriage
• Too early
– would re scan
• Unsure
– Do bloods
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Pre 2012 : “ pregnancy of uncertain viability “
RCOG (2006 )
Gestational Sac > 20 mm
Embryo > 6mm
ACR ( 2000)
Gestational Sac >16 mm
Embryo > 5mm
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Why the change ?
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Why the change ? Nov 2011 Vol 38 Number 5
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• “ clinicians cannot be certain that the current guidelines afford them a 100 % specificity in the diagnosis of miscarriage “
• “ that is to say that it is possible for some women with a viable pregnancy will be inappropriately labeled as having a miscarriage “
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In brief : 1060 women attending EPAU’s LondonProspective observational TVSIndication : bleeding, pain , past historyEnd point 11-14 week viability
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• Demonstrated that with MSD > 20 mm
– One viable pregnancy for 200 classified as a miscarriage
– False positive rate was 4.4 % if MSD > 16 mm
• Recommended that increasing the CRL/MSD definition of miscarriage , the false positive rates fall to zero
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• “ slow or absent growth of MSD is not necessarily associated with a miscarriage “
• “ Failure to visualise a yolk sac or embryo on rpt scan was a defining feature of a failed pregnancy “
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• A TVS should be performed in all cases where there is any doubt about the diagnosis and /or a woman requests a repeat scan and this should be performed at an interval of at least one week from the initial scan before medical or surgical measures are undertaken .
• No growth in gestational sac size or CRL is strongly suggestive of a non viable pregnancy in the absence of embryonic structures
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New guidelines for the diagnosis of miscarriage
RCOG
Gestational Sac > 25 mm
Embryo > 7 mm
ACOG /ACR / AJUM/SRU
Gestational Sac > 25 mm
Embryo > 7mm
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Mean Gestational sac diameter 21mm CRL 6.5 mm and no FH
• Miscarriage
• Too early
– would re scan
• Unsure
– Do bloods
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Mean Gestational sac diameter 21mm CRL 6.5 mm and no FH
• Miscarriage
• Too early
– would re scan
• Unsure
– Do bloods
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But ..... More Questions
• What about the failed pregnancy that never reaches this 7/25 cut off ?
• When should we repeat the scan ?
• What should we expect to find on repeat scan to diagnose miscarriage ?
• What about gestational age ?
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Diagnosis of miscarriage trial ( DOM )
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CRL 7.1 mm
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MSD 27 mm with no visible emnryo
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Scan 2 weeks apart intrauterine GS with YS but no embryo
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Miscarriage management
• Appropriate training and equipment
• Be aware of new diagnostic criteria
• Stipulate ultrasound findings on repeat scan to define miscarriage
• Manage patient expectation on the repeat scan
• Remember expectant management is unlikely to be harmful but intervention certainly can be
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Thank you for your attention