Issues in Early Pregnancy

ACOG District I Medical Student

Teaching Module 2008
When a woman presents with an early
pregnancy
Ask yourself two questions
Where is this pregnancy?

Is it viable?
Where is this pregnancy?

In a woman with an early pregnancy you must
determine if the pregnancy is intrauterine or
an ectopic, because her life could depend on
it!

How to you determine location of the
pregnancy?
First determine dating by LMP
Then perform ultrasound
If you can see location of the pregnancy, you
are done!
If you cannotit becomes more complicated
Early pregnancy with unknown
location
Check a serum BHCG
If it is above the discriminatory zone (DZ)
(this is different at every hospital) an
intrauterine pregnancy should be seen
Then do an ultrasound to see if you see the
pregnancy

Early pregnancy with unknown
location
If BHCG>DZ and pregnancy seen in the uterus,
you are done
If BHCG>DZ and no pregnancy seen in the
uterus, it is an ectopic until proven otherwise!
Ectopic pregnancy
2% of all pregnancies
Risk factors include prior tubal surgery, prior
ectopic, current IUD use, history of PID, or DES
exposure
A woman can present with abdominal pain or
bleeding or be asymptomatic!
Ectopic Pregnancy
95% are in the fallopian
tube (70% ampulla, 12%
isthmus, 11% fimbria,
2% interstitial/cornual)
Ovarian occurs about
3% of the time,
abdominal 1% of the
time and cervical <1%
of the time
Seeber 2006
Early pregnancy with unknown
location
If BHCG< DZ and you do not see the
pregnancy on the ultrasound consider your
patient
Is she.
Unstable or stable
Have pain? Have risk factors for ectopic?
Your differential diagnosis is :intrauterine
pregnancy just too small to see on ultrasound vs
ectopic


Early pregnancy with unknown
location
Generally, BHCG will double in 48 hours
If the patient is stable you can have her return
in 48 hours for repeat BHCG
If is doubling appropriately, likely normal
intrauterine pregnancy and can order
ultrasound when >DZ
If not doubling appropriately consider
treatment for ectopic (methotrexate or
surgery)
Now you know locationnow what?
An ectopic pregnancy can be treated either
medically with methotrexate or surgically
The next step with an intrauterine pregnancy
is determining viability
Viability
When you have an intrauterine pregnancy
there are several possibilities
1- Normal
2 - Miscarriage (there are different types!)
3 - Molar pregnancy
A viable pregnancy is an intrauterine
pregnancy that has cardiac motion-should see
by 7-8 weeks


Intrauterine pregnancy
First finding on US is an empty gestational sac
But cannot say that it is an intrauterine
pregnancy until you see a yolk sac or a fetal
pole
Intrauterine Pregnancy
Finding Gestational Age
Gestational Sac 5 weeks
Yolk sac 6 weeks
Embryo 6 weeks
Cardiac Activity 7 weeks
Yolk sac by 5 weeks
www.advancedfertility.com
Fetal Pole by 6-7 weeks
www.advancedfertility.com
Types of nonviable intrauterine
pregnancies
Anembryonic (blighted ovum)
Threatened abortion
Inevitable abortion
Complete abortion
Missed abortion

Anembryonic gestation
No yolk sac or fetal pole
Mean gestational sac
diameter of 30 mm
www.gloriaspregnancyinfo.com
Threatened abortion
First trimester bleeding
Fetal pole with a heartbeat
If there is a heartbeat there is less than 10%
chance of miscarriage
Inevitable abortion
Deformation and/or descent of gestational sac
with a dilated cervix
Complete abortion
Products of conception completely expelled
Missed abortion
Intrauterine pregnancy with an embryo, but
no cardiac activity by 8 weeks gestation
Now you know the basic issues in
early pregnancy!!

Algorithm that might help you
Seeber 2006
Sources
Frishman, Gary, et al. Women and Infants Beta book.
Merz, Eberhard. Ultrasound in Obstetrics and Gynecology Vol 1: Obstetrics.
Stuttgart: Georg Thieme Verlag, 2005.
Mukul, Liberato and Stephanie Teal. Current Management of Ectopic Pregnancy.
Obstetrics & Gynecology Clinics of North America. 34 (2007): 403419.
Seeber, Beata E, and Kurt T Barnhart. Suspected Ectopic Pregnancy. Obstetrics &
Gynecology. 107 (2006): 399-413 .
www.advancedfertility.com
www.gloriaspregnancyinfo.com