Instructions: Listen to the podcast episode available below, and then submit your answers to the multiple choice questions.  You will review the answers and the material covered during your next Continuity Clinic Session.  

Early Unlocated Pregnancy

Early Unlocated PregnancyCREOGs Over Coffee
00:00 / 01:04

1. A 22yo G2P1 presents with vaginal spotting. Urine pregnancy test is positive. Quantitative serum b-HCG is 1625 mIU/mL. There are no adnexal masses. There is no free fluid in the cul de sac. What is the next best step?

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Show Explanation

  • The diagnosis is pregnancy of unknown location with a differential including viable IUP, failed pregnancy or ectopic pregnancy

  • A recent cross-sectional study found an updated discriminatory value of 3510 mIU/mL for transvaginal ultrasound- at this level, there was a 99% probability of detecting a gestational sac.

  • The previously used 1000-2000 mIU/ML would only have detected 80% of viable pregnancies in this new study

  • If the patient is stable, it is reasonable to repeat b-HCG level in 48-72 hours

  • For a viable pregnancy, a 66% increase in the serum b-HCG level over 48 hours is expected

  • BUT viable pregnancies can still have an “inappropriate” rise and ectopic pregnancies can have an “appropriate” rise

2. A 30 yo G3P0111 presents for a dating ultrasound. She is 5w5d by LMP. She reports intermittent light vaginal bleeding over the last week. Pelvic exam prior to her scan demonstrates a closed cervix with no active bleeding. She is Rh positive. Ultrasound shows a gestational sac with a yolk sac seen by transvaginal imaging. What is the best next step in management to confirm viability?

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  • The presence of a yolk sac identifies this as an intrauterine pregnancy so serum b-HCG level is not necessary

  • Per ACOG, the following findings are diagnostic of early pregnancy loss:

  • CRL of 7 mm or greater with no heartbeat

  • Mean sac diameter of 25 mm or greater and no embryo

  • Absence of embryo with a heartbeat 2 weeks or more after a scan that showed a gestational sac without a yolk sac

  • Absence of embryo with a heartbeat 11 days or more after a scan that showed a gestational sac with a yolk sac

  • Thus, in order to confirm viability for this patient, it would make most sense to repeat an ultrasound in 11 or more days

3. A 30 yo G6P0050 with a history of recurrent pregnancy loss presents for a viability scan. Per ACOG, which of the following is suggestive (but not diagnostic) of early pregnancy loss?

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  • The following findings are suggestive (but not diagnostic) of early pregnancy loss:

  • Crown rump length < 7 mm with no heartbeat

  • Mean sac diameter of 16-24 mm with no embryo

  • Absence of embryo with heartbeat 7-13 days after an ultrasound scan than showed a gestational sac without a yolk sac

  • Absence of embryo with a heartbeat 7-10 days after an ultrasound scan that showed a gestational sac with a yolk sac

  • Absence of embryo for 6 weeks or longer after LMP

  • 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 the size of the embryo (less than 5 mm difference between mean sac diameter and CRL)