PowerPoint Presentation · “Blighted ovum” Transvaginal US with gestational sac but no visible yolk sac or embryo ©2016 MFMER | slide-17 TERMINOLOGY Embryonic / fetal demise

8/18/2018

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©2016 MFMER | slide-1

EARLY PREGNANCY LOSS

Mari Charisse Trinidad, MDDivision of Maternal Fetal MedicineDepartment of Obstetrics and Gynecology


CONFLICT OF INTEREST

• I have no financial conflict of interest to disclose


OBJECTIVES

• Define early pregnancy loss

• Describe approach to diagnosis of early pregnancy and early pregnancy loss

• Describe management options available for early pregnancy loss


EARLY PREGNANCY LOSSBACKGROUND


INCIDENCE

10%


INCIDENCE

Occurs in 10% of all clinically recognized pregnancies

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ETIOLOGY

Approximately 50% of all cases of early pregnancy loss are due to fetal chromosomal abnormalities


RISK FACTORS

MOST COMMON

Advanced maternal age

Prior early pregnancy loss


TERMINOLOGY

Pregnancy loss

Early pregnancy loss

Miscarriage

Spontaneous abortion

Complete abortion

Incomplete abortion

Inevitable abortion

Anembryonic pregnancy

Embryonic / fetal demise


TERMINOLOGY


A nonviable intrauterine pregnancy within

the first 12 6/7 weeks of gestation


TERMINOLOGY

Miscarriage

Lay term for preterm loss


TERMINOLOGY


Clinical term that can be used

interchangeably with early pregnancy loss

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TERMINOLOGY

Complete abortion

Clinical diagnosis

History of positive pregnancy test

Vaginal bleeding with passage of tissue

Closed cervical os at time of examination

Transvaginal US with absence of gestational

sac


TERMINOLOGY

Incomplete abortion

Clinical diagnosis


Vaginal bleeding and passage of tissue

Open cervical os

Transvaginal US with heterogenous tissue

distorting the endometrial canal with or

without a gestational sac


TERMINOLOGY

Inevitable abortion

Clinical diagnosis


Vaginal bleeding without passage of tissue

Open cervical os

Transvaginal US with gestational sac in the

uterus


TERMINOLOGY


“Blighted ovum”

Transvaginal US with gestational sac but no

visible yolk sac or embryo


TERMINOLOGY


“Missed abortion”

Transvaginal US showing embryo or fetus

with no cardiac activity in an asymptomatic

patient


TERMINOLOGY

Expectant management

No intervention and await spontaneous

passage of tissue

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TERMINOLOGY

Medical management

Use of medications to expel products of

conception


TERMINOLOGY

Surgical management

Mechanical removal of products of

conception


EARLY PREGNANCY LOSSMAKING THE DIAGNOSIS


DIAGNOSIS OF EARLY PREG LOSS

Symptoms

Human chorionic gonadotropin (hCG)

Pelvic ultrasonography


DIAGNOSIS

Symptoms

Vaginal bleeding

Abdominal pain, including lower abdominal

cramping

Nonspecific


DIAGNOSIS OF EARLY PREG LOSS

Human chorionic gonadotropin (hCG)


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DIAGNOSIS

Beta human chorionic gonadotropin

Serum hCG concentration is measured with

the use of the World Health Organization 3rd

or 4th International Standard

A positive serum pregnancy test is defined

by a serum hCG concentration above a

positivity threshold (5 mIU/ml)


DIAGNOSIS


Discriminatory level for transvaginal

ultrasound

• Serum hCG level above which, if no

gestational sac is seen, one can be sure a

normal pregnancy is not present

• Traditional teaching: Treat as ectopic

pregnancy or abnormal pregnancy

• Commonly used level: 2000 mIU/ml


DIAGNOSIS


Misunderstanding HCG role

• Not the lowest level can detect a

gestational sac

• A SINGLE HCG does not indicate

pregnancy location or viability

• 33% of patients without a gestational sac >2000 mIU/ml later had

normal pregnancy

• Highest HCG without gestational sac resulting in normal pregnancy

was 4336 mIU/ml


DIAGNOSIS


Low HCG should not preclude ultrasound

• Ectopic pregnancy can occur with a low

hCG level

• May see gestational sac below the

discriminatory level

New data suggests we should not rely on

discriminatory level when no ectopic

pregnancy seen


DIAGNOSIS


Transabdominal

Transvaginal

“Minimum quality criteria include

transvaginal assessment of the uterus and

adnexa and transabdominal evaluation for

free peritoneal fluid and a mass high in the

pelvis; oversight by trained physicians…”


TERMINOLOGY

Pregnancy loss


Miscarriage


Complete abortion

Incomplete abortion

Inevitable abortion



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©2016 MFMER | slide-31 ©2016 MFMER | slide-32

CONTEMPORARY TERMINOLOGY

Viable pregnancy

Nonviable pregnancy

Intrauterine pregnancy of uncertain viability

Pregnancy of unknown location



Viable pregnancy

A pregnancy is viable if it can potentially

result in a liveborn baby



Nonviable pregnancy

A pregnancy is nonviable if it cannot

possibly result in a liveborn baby

Ectopic pregnancies

Failed intrauterine pregnancies



Intrauterine pregnancy of uncertain viability

A woman is considered to have an

intrauterine pregnancy of uncertain viability

if

transvaginal ultrasonography shows an

intrauterine gestational sac

with no embryonic heartbeat (and no

findings of definite pregnancy failure)



Pregnancy of unknown location

A woman is considered to have a pregnancy

of unknown location

if she has a positive urine or serum

pregnancy test and

no intrauterine or ectopic pregnancy is seen

on transvaginal ultrasonography

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©2016 MFMER | slide-37 ©2016 MFMER | slide-38

Society of Radiologists in Ultrasound Guidelines for Transvaginal Ultrasonographic

Diagnosis of Early Pregnancy Loss

FINDINGS DIAGNOSTIC OF


FINDINGS SUGGESTIVE, BUT

NOT DIAGNOSTIC OF, EARLY

PREGNANCY LOSS

Crown-rump length of 7 mm or

greater and no heartbeat

Mean sac diameter of 25 mm or

greater and no embryo

Absence of embryo with heartbeat 2

weeks or more after a scan that

showed a gestational sac without a

yolk sac

Absence of embryo with heartbeat

11 days or more after a scan that

showed a gestational sac and a yolk

sac








PREGNANCY LOSS

Crown-rump length of less than 7

mm or greater and no heartbeat

Mean sac diameter of 16-24 mm

and no embryo


7-13 days after a scan that showed

a gestational sac without a yolk sac


7-10 days or more after a scan that


sac








PREGNANCY LOSS

Absence of embryo for 6 weeks or

longer after last menstrual period

Empty amnion (amnion seen

adjacent to yolk sac, with no visible

embryo)

Enlarged yolk sac (greater than 7

mm)

Small gestational sac in relation to

size of embryo (less than 5 mm

difference between mean sac

diameter and crown rump length)

Criteria are from the Society of Radiologists in Ultrasound Multispecialty Consensus Conference on Early First Trimester

Diagnosis of Miscarriage and Exclusion of a Viable Intrauterine Pregnancy, October 2012.


24 year old G1P0 at 10 0/7 weeks by LMP


No fetal cardiac activity

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FOLLOW-UP?


33 year old G3P1011 at 9 weeks by LMP


Next steps?


Transvaginal ultrasound


Mean gestational sac diameter 11.5 mm


FOLLOW-UP?

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FINDINGS SUSPICIOUS FOR PREGNANCY FAILURE

When there are findings suspicious for pregnancy failure, follow-up ultrasonography at 7 to 10 days to assess the pregnancy for viability is generally appropriate


MANAGEMENT OF EARLY PREG LOSS


Medical management

Surgical management




Limited to pregnancy loss in the first

trimester

With adequate time (up to 8 weeks), 80%

success

May be more effective in symptomatic

(incomplete spontaneous abortion) than in

asymptomatic women (e.g., missed abortion

or anembryonic pregnancy)©2016 MFMER | slide-52



No consensus for complete expulsion

pregnancy tissue

Ultrasound criteria

Patient reported symptoms

Commonly used criterion: Absence of

gestational sac and an endometrial

thickness less than 30 mm



Medical management

Misoprostol (prostaglandin E1 analogue)

Option for those who are interested

shortening the time to complete expulsion

but prefer to avoid surgical evacuation

Compared to placebo: Reliably reduces the

need for uterine curettage by up to 60% and

shortens time to completion



Medical management

Misoprostol 800 μg vaginally

Repeat dose on day 3 if indicated

Offer expectant management if clinically

stable

Consider vacuum aspiration if expulsion

incomplete

Zhang J, et al. N Engl J Med. 2005

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Medical management

Best evidence:

Larger dose more effective

Vaginal or sublingual more effective than

oral



Medical management

Insufficient evidence: Addition of

mifepristone (progesterone receptor

antagonist)

Insufficient evidence: Use among women

with incomplete pregnancy loss

Does not clearly result in higher rates

of complete evacuation over expectant

management (at 7-10 days 80% vs 52-85%)



Surgical management

Dilatation and curettage

Manual vacuum aspiration



Surgical management

SUCTION CURETTAGE: Superior to the use

of sharp curettage alone

Location: Office or Operating Room

Suction Source: Electric vacuum source or

manual vacuum aspiration



Surgical management

AHRP Core©2016 MFMER | slide-60


Surgical management

World Health Organization, 2003

“…Health managers and policy makers should make all possible efforts to replace sharp curettage (D&C) with vacuum aspiration.”

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OTHER CONSIDERATIONS

• RH negative status

• Disposition of products of conception

• Grief and bereavement


EARLY PREGNANCY

INTRAUTERINE

NO YES


EARLY INTRAUTERINE PREGNANCY

VIABLE

NO YES








PREGNANCY LOSS

Crown-rump length of 7 mm or

greater and no heartbeat

Mean sac diameter of 25 mm or

greater and no embryo

Absence of embryo with heartbeat 2

weeks or more after a scan that

showed a gestational sac without a

yolk sac


11 days or more after a scan that


sac








PREGNANCY LOSS

Crown-rump length of less than 7

mm or greater and no heartbeat

Mean sac diameter of 16-24 mm

and no embryo


7-13 days after a scan that showed

a gestational sac without a yolk sac


7-10 days or more after a scan that


sac








PREGNANCY LOSS

Absence of embryo for 6 weeks or

longer after last menstrual period

Empty amnion (amnion seen

adjacent to yolk sac, with no visible

embryo)

Enlarged yolk sac (greater than 7

mm)

Small gestational sac in relation to

size of embryo (less than 5 mm

difference between mean sac

diameter and crown rump length)

Criteria are from the Society of Radiologists in Ultrasound Multispecialty Consensus Conference on Early First Trimester

Diagnosis of Miscarriage and Exclusion of a Viable Intrauterine Pregnancy, October 2012.

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EARLY INTRAUTERINE PREGNANCY

NONVIABLE

EXPECTANT MEDICAL SURGICALManual vacuum aspiration

Dilatation and curettageMisoprostol


OBJECTIVES

• Define early pregnancy loss

• Describe approach to diagnosis of early pregnancy and early pregnancy loss

• Describe management options available for early pregnancy loss


[email protected]


REFERENCES

American College of Obstetricians and Gynecologists (ACOG): Practice bulletin on early pregnancy loss (2015, Reaffirmed 2017).

NICE: Clinical guideline on ectopic pregnancy and miscarriage – Diagnosis and initial management (2012).

Zhang J, Gilles JM, Barnhart K, Creinin MD, Westhoff C, Frederick MM. A comparison of medical management with misoprostol and surgical management for early pregnancy failure. N Engl J Med. 2005;353:761–9.

Bagratee JS, Khullar V, Regan L, Moodley J, Kagoro H. A randomized controlled trial comparing medical and expectant management of first trimester miscarriage. Hum Reprod. 2004;19:266–71.

WHO. Safe Abortion: Technical and Policy Guidance for Health Systems. Geneva, Switzerland: World Health Organization, 2003.

Society of Radiologists in Ultrasound Multispecialty Consensus Conference on Early First Trimester Diagnosis of Miscarriage and Exclusion of a Viable Intrauterine Pregnancy, October 2012.

Documents

PowerPoint Presentation · “Blighted ovum” Transvaginal US with gestational sac but no visible yolk sac or embryo ©2016 MFMER | slide-17 TERMINOLOGY Embryonic / fetal demise