Abnormal First

Trimester:
Pregnancy Failure
PP1 2021
Definitions
Threatened Abortion – vaginal bleeding in a viable pregnancy up to 20 weeks GA in the
presence of a closed cervix
Completed / Spontaneous Abortion – complete passage of the embryo, amnion and
chorion
Incomplete Abortion (retained products of conception or POC): retained ”tissues” or
incomplete passage of any of the structures listed above

◦ Missed Abortion – a term not recommended (does not adequately describe pathophysiologic
events but often refers to all products of conception retained after embryonic demise)
Definitions

Habitual Abortion / serial miscarriage: 3 or more recurrent, consecutive miscarriages

Embryonic demise: presence of an embryo without cardiac activity when cardiac activity is
expected (ie. Nonviable)
Early abortion (miscarriage)– less than 12 weeks
Late abortion (miscarriage) – between 12 and 20 weeks
Medical (Therapeutic abortion) –medical or surgical treatment to end pregnancy
Why do pregnancies fail?

40 – 50% are unexplained

 REMEMBER!
Patients may be unsure of menstrual dates or have
irregular periods!

Discriminatory levels are extremely important!

Ultrasound Evidence of Pregnancy Failure:
1. Gestational Sac Issues
• ABNORMAL LOCATION: Cornua or cervical location
• ABNORMAL APPEARANCE:
• centrally located and tear dropped shaped may represent a pseudogestational sac (fluid
collection) which may occur with ectopic (tubal pregnancy)
• Collapsed
• Containing debris
• Thin decidual reaction around sac (< 2 mm)
• Small sac size compared to embryo (difference of less than 5 mm between the GS and the CRL)
• ABNORMAL SIZE / GROWTH:
• Normally grows 1 mm / day
• ANEMBRYONIC PREGNANCY - Large sac that does not contain an embryo (MSD > 25mm)
Gestational Sac
 Blighted Ovum – Anembryonic
Pregnancy
•a blastocyst is formed
from a fertilized ovum, but
the fetal
pole/embryo never
develops
•Clinical – no symptom or
bleeding or low or slowly
rising hCG levels
 MSD = 27.7 mm

Source Atlas of Ultrasound in Obstetrics & Gynecology: A Multimedia Reference 3 rd ed. Doubilet, Benson & Benacerraf – Wolters Kluwer
Ultrasound Evidence of Pregnancy Failure:
2. Yolk Sac
• Normally identified by 5.5 weeks (when GS is ~8-10 mm but sometimes not
until 20 mm)
• Increased in size (greater than 6 mm) is an indicator of abnormal pregnancy
progression and also may be an indicator of abnormal embryo
• Shape (not as significant as size)
• Irregular (non-circular) shape – crenulated
• Wrinkled margins
• Indented walls
• Collapsed walls
• Thick echogenic walls
• Echogenic spots or bands
• Calcified – always correlates with embryonic demise
Ultrasound Evidence of Pregnancy Failure:
3. Amniotic sac / Amnion
• Normally identified at the same time as the embryo
•A small or non-visualized embryo in a well formed amniotic cavity is
suggestive of pregnancy failure (Empty Amnion)
Source Atlas of Ultrasound in Obstetrics & Gynecology: A Multimedia Reference 3 rd ed. Doubilet, Benson & Benacerraf – Wolters Kluwer
Amniotic Sac – too small / too large
Ultrasound Evidence of Pregnancy
Failure: 4. Embryonic Heart Rate
 HR less than 85 bpm when greater than 7
weeks is associated with preg failure
Arrhythmia is a negative indicator
Absent EHR is EMBRYONIC DEMISE when
CRL is greater than or equal to 7 mm
Need 2 sets of eyes to confirm
M-mode
Video clip
◦ Make sure to scan through
Symptoms of Pregnancy Complications:
Vaginal Bleeding and / or Cramping
Subchorionic hematoma vs Implantation bleed – both hypoechoic

 Subchorionic hematoma – pulling away / elevation of the chorion / separation from

decidua vera
 Often brighter blood, may have cramping

 Implantation bleed – from trophoblast invasion

 Often brown blood
Subchorionic Hematoma (SCH)
Prognosis - related to size of bleed around sac
CASE 1 CASE 2
Source Atlas of Ultrasound in Obstetrics & Gynecology: A Multimedia Reference 3 rd ed. Doubilet, Benson & Benacerraf – Wolters Kluwer
Threatened abortion
Clinical symptoms:
oVaginal bleeding
oCramping
oIncreased risk with increase symptoms

50% loss rate

 Inevitable Abortion
AKA: Imminent, impending
Miscarriage in progress, cannot be halted
Sonographically
◦ Cervix dilated
◦ Sac low in uterus/ in cervix
◦ +/- FHR
Clinical: bleeding and cramping
 Complete / Spontaneous Abortion
oNo residual products of conception
oEndometrium smooth <14mm
oNo feeding vessels
oMay have positive but falling BHCG
oClinical presentation – heavy bleeding
and/or cramping with clots passed but
subsiding
Incomplete Abortion (RPOC)
Expulsion of some of the products
RPOC – retained products of conception
Tissue may be trophoblastic and/or fetal tissue
Sonographically
◦ Abnormal gestational sac
◦ Vascular or avascular
◦ Mixed echogenicity
◦ Thick irregular endometrium
◦ Shadowing
Complication: Septic Abortion
Delayed diagnosis of incomplete abortion leading to infection
Basically RPOC
Presents clinically with fever and previous symptoms (bleeding,
cramping)
Sonographically: identification of intrauterine shadowing evidence
of gas/air

Treated with D&C (Dilation and Curretage)

Irregular sac and
heterogenous 3
decidual reaction
vascularity
within
endometrium
Very thick
heterogenous
endometrium
avascular

5
SEPTIC:
shadowing (from
either calcified
products or gas from
breakdown)
5
Incomplete Abortion

Radiopaedia.(2011)[Edema].Retrieved from http://radiopaedia.org/articles/fetal-death-2

Chorionic Bump
•rare abnormality of the gestational sac uncommonly seen in a 1st
trimester scan
•presents as an irregular, convex bulge from the choriodecidual
surface into the gestational sac
•is associated with increased first trimester loss
•may represent a small hematoma bulging into the gestational sac or
a blighted second pregnancy that is being reabsorbed.
Chorionic Bump
Pseudocyesis
AKA – false pregnancy, hysterical pregnancy
Patient develops all the clinical symptoms (weight gain, nausea, feels
movement)
Normal pelvic exam
Negative hCG
 History Taking Questions
Pregnancy test?
◦ When? Previous miscarriages? -
◦ More than one? try to ask before you start
the exam (not while you
Cramping?
◦ When did it start/stop? are scanning as this will
◦ Sharp or dull cramps? alarm the patient)
Bleeding?
◦ How much? (ie what is the volume)
◦ What color?
◦ Any clots?