embryonic phase

 The embryonic phase of

development is complete by
the end of the 10th G.wk
 Although a variety of terms are
used to describe early pregnancy
failure, in the presence of clear-cut
sonographic evidence that a
nonliving embryo is present, the
term embryonic demise should
apply
 Early pregnancy loss
Only about 1/2 of zygotes
persist as a clinical
(symptomatic or noticeable)
pregnancy.
 Anatomic Points

 True
gestational sacs implant into the
endometrial lining, and are seen
eccentric to the endometrial
canal. Fluid collections within the canal
are not true gestational sacs.
 Anatomic Points

 The Gestational sac and yolk sac are

seen beginning at 4.5-5 weeks, before
a recognizable embryo is seen
 Anatomic Points
 As the gestation enlarges into the
endometrial cavity, only the early placenta
need be in tight contact with the decidua.
Small amounts of bleeding into the cavity
are commonly seen, and may surround
much of the gestational sac, but if the
decidua basalis remains intact, the
gestation can and usually does continue to
develop normally.
 causes
 Some causes of first trimester demise
are well understood; however, in most
instances, the etiology is unknown
(Moore, 1998 )
 causes
 Chromosome abnormalities
are the leading known cause of pregnancy
loss. An estimated 6-7% of zygotes have
chromosome aberrations (Moore, 1998),

 and more than 95% of chromosomally

abnormal concepti die in utero
 causes
 cytogenic abnormalities
in 20% in women who undergo in vitro fertilization
(Bateman, 1992) and
in 70% of women with spontaneous abortion
(Ohno, 1991).
 many chromosome aberrations increase with
advancing maternal age (Hook, 1981). This is
particularly true for Down syndrome (trisomy 21)
but is also evident with other less common
trisomies
 environmental causes
 immunologic factors,
 drugs,
 infectious agents,
 alcohol,
 smoking,
 environmental chemicals,
 radiation
 environmental causes
 Exposure before 5 weeks gestational age
(GA), has an all-or-none result such that the
embryo will either die or be unaffected
(Moore, 1998).
 (5-10 wk) usually affects organ development
and results in either demise or severe
congenital abnormalities.
 Luteal phase defect
 Once implantation has occurred, another
cause of early pregnancy failure relates to an
inability of the corpus luteum to adequately
support the conceptus (Blumenfeld, 1992).
 This condition, which tends to occur with
maternal obesity and/or advancing maternal
age, can be treated successfully during the
embryonic phase of development by
administrating human choriogonadotropin
(hCG).and /or progestrone.
 Uterine causes
 A developmental uterine anomaly such as a
uterine septum or acquired uterine
anomalies such as submucosal, large, or
degenerating leiomyomas also can increase
the incidence of embryonic demise
Clinical Details
 first trimester
25%

mild vaginal
bleeding and/or
cramping

50% fail 50%continue

 Clinical Details

 Some women with embryonic demise

will be asymptomatic, and in these
patients the diagnosis may be
suggested based on subnormal
uterine growth,
 Clinical Details
 The earliest visible
gestational sac is
seen at 4.5 weeks as
an echogenic ring,
with a tiny central
hypoechoic area.

Gestational. Age (days)= 30 + Mean Sac Diam.(mm.)

 Clinical Details

 To confidently diagnose an IUP, most

sonographers rely on the double decidual
sac (DDS) finding, which is not universally
present until the MSD is 10 mm (40 days
GA) (Nyberg, 1983).
 This very small sac (arrow) is positioned within the
anterior endometrium. Note the linear central cavity echo
positioned just deep to the sac. This relationship
characterizes a normal-appearing intradecidual sac sign.
 Clinical Details
 when using a transabdominal approach,
cardiac activity should be visible by 8 weeks
GA., 9 mm should be considered the
discriminatory embryonic length for detecting
cardiac motion
 with a transvaginal approach. can detect
cardiac activity approximately 2 weeks earlier
or by 6 weeks GA. 5mm be considered the
discriminatory embryonic length for detecting
cardiac motion
 the discriminatory value

Cardiac Cardiac
activity activity

 TAUS:8WK,  TVUS:6WK

9mm,CR 5mm,CR
25MSD
 Clinical Details
 A limitation of the transvaginal approach is if a
large pelvic mass is present. Most often, large
or strategically placed calcified uterine fibroids
cause this problem. Under these
circumstances, an abdominal approach
should be used in an effort to image the
uterus and its contents.
 Clinical Details
 Using a vaginal yolk sac

approach, the
yolk sac should
be observed by
5.5 weeks GA.
 Clinical Details

 Yolk sac should be seen when sac is 10mm.

MSD by vaginal probe, or 20 mm. MSD by
abdominal probe.
NORMAL YOLK SAC

TAUS TVUS

(MSD) is 20 mm MSD is10 mm

7 weeks 5.5 weeks

Yolk sac must be visible

 Yolk sac
3mm

A normal appearing yolk sac (arrow) is

seen on this transvaginal scan done at
5.5 weeks gestational age.
 An abnormally large yolk sac is present (arrow)
within this gestational sac. Diameter measured
10 mm. Follow-up imaging confirmed a failed
pregnancy.
 If no yolk sac
 If a small saclike structure is imaged but it does
not contain a yolk sac, it is often not possible to
determine if the intrauterine finding is the result of
an early IUP or a pseudosac associated with an
ectopic pregnancy.
 In these instances, careful evaluation of the
adnexa may be helpful to detect an ectopic
pregnancy. Occasionally, serial ultrasound and/or
hCG determinations may be required to determine
the etiology for the intrauterine sac
Visualizing a dead
embryo
 Visualizing a dead embryo
 using a transabdominal approach, 9 mm
should be considered the discriminatory
embryonic length for detecting cardiac
motion. Used in this manner,

( the discriminatory level denotes the numeric value when a certain

finding should always be present. )
 Visualizing a dead embryo
 when a transvaginal approach was used,
5 mm be considered the discriminatory
embryonic length for detecting cardiac
motion.
 the discriminatory value

Cardiac Cardiac
activity activity

 TAUS:8WK,  TVUS:6WK

9mm,CR 5mm,CR
25MSD
 Visualizing a dead embryo
 an embryo exceeds the discriminatory length and
cardiac activity is absent, a nonviable gestation
should be diagnosed.,
 this observation should be made by two
independent observers, and interpretive caution
must be exercised in any questionable case.
Documentation should be available by M mode
imaging and/or by obtaining a videotape or video
clip.
 NO
TVUS CRL>5MM CARDIAC
MOTION

NO
TAUS CRL>9MM CARDIAC
MOTION

FETAL
DEMISE
 Visualizing a dead embryo
 If the length of the embryo is less than the
discriminatory value, the patient should be
managed expectantly,
 a repeat ultrasound examination should be
performed when the expected embryonic
CRL exceeds the discriminatory value.
Alternatively, or additionally, the level of
serum hCG may be useful for determining
whether a normal IUP is present.
 Visualizing a living embryo
 Although seemingly a paradox, it is well known
that detecting cardiac activity when using a
vaginal transducer does not guarantee as
favorable an outcome as detecting cardiac
activity when using an abdominal transducer
 the vaginal approach detects cardiac activity
earlier when the incidence of pregnancy loss is
relatively higher.
Predicting a poor
outcome
 Predicting a poor outcome
 a number of other important observations have
been made, which, when observed with a living
embryo, are predictive of a poor outcome (Falco
1996).
Predicting a poor outcome
mean embryonic heart mean gestational sac
rate (MEHR) size (MSS)

Abnormal yolk Subchorionic

sac/amnion hemorrhage

Abnormal sac
criteria Doppler findings
 Predicting a poor outcome

(MEHR)

 At 5-6 weeks GA, the mean embryonic

heart rate is 101 beats per minute (bpm).

 This rate increases to 143 bpm by 8-9

weeks GA
 Predicting a poor outcome
(MEHR)
 it is not unusual for an initially detected
embryonic heart rate to be somewhat slower than
the fetal heart rate recorded later in pregnancy.
An unusually slow heart rate is cause for
concern. In one study, all embryos from 5+ to 8+
weeks GA in which the heart rate was less than
85 bpm resulted in spontaneous miscarriage
(Benson, 1994
 At 5.5 weeks gestational age, the embryonic
heart rate was 92 beats per minute. Follow-up
scan revealed embryonic demise
 Predicting a poor outcome
(MSS)
 Small sac size: From 5.5-9
weeks GA, the mean gestational
sac size (MSS) is normally at
least 5 mm greater than the CRL
 Predicting a poor outcome

(MSS)
When this difference is less than
5 mm, the subsequent
spontaneous abortion rate
exceeds 90% (Bromley, 1991)
(MSS)

 This embryo was 8 weeks gestational age.

Lack of fluid surrounding the embryo results
in a disproportionately small sac. A follow-up
scan 1 week later revealed demise
 Predicting a poor outcome
Subchorionic hemorrhage

 Subchorionic hemorrhage: As many as 18% of

women with vaginal bleeding during the first half
of pregnancy have sonographic evidence for a
Subchorionic hemorrhage as the etiology for their
bleeding (Pederson, 1990).
Early pregnancy bleeding

18%

Subchorionic hemorrhage
 Predicting a poor outcome
Subchorionic hemorrhage
 Several authorities have suggested that
the size of the blood clot can be used to
predict the outcome (Abu-Yousef 1987);
this has not been universally accepted
(Dickey, 1992).
 A large Subchorionic hemorrhage is present
superior to the gestational sac (white arrow).
Follow-up scan revealed embryonic demise
 Predicting a poor outcome
Subchorionic hemorrhage

Hemorrhage volume (Estimated from formula

Length (cm) X Height (cm) X Depth (cm) X 0.52 =
Volume ml), less then 75-200 ml. is often
associated with continued development
Abnormal yolk sac/amnion
NORMAL YOLK SAC
TAUS TVUS

(MSD) is 20 mm MSD is 8 mm

GA of 7 weeks GA of 5.5 weeks

Yolk sac must be visible

 Abnormal yolk sac/amnion
 The amnion develops somewhat earlier than
the yolk sac, but because this membrane is so
thin, it is more difficult to visualize than the
yolk sac. Normally, the amnion is visible on
transabdominal scans late in the embryonic
period. If the amnion is easily seen, it is
probably too thick and most likely is abnormal
 Abnormal yolk sac/amnion
 Other features consistent with pregnancy
failure include a visible amnion without a
simultaneously visible yolk sac, embryo, or
cardiac activity. An enlarged amniotic sac is
another sonographic sign that predicts a failed
pregnancy or embryonic death (Horrow,
1992).
 An abnormally large yolk sac is present (arrow)
within this gestational sac. Diameter measured 10
mm. Follow-up imaging confirmed a failed
pregnancy.
 Doppler findings
 conflicting reports exist with regard to the
usefulness of first trimester Doppler for predicting
pregnancy outcome. Some reports suggest if the
resistive index is measured at the Subchorionic
level and exceeds .55, a high likelihood of
spontaneous abortion exists (Jaffe, 1995);
however, others claim that Doppler analysis of
these vessels are not predictive of outcome
(Frates 1996).
Abnormal sac criteria
 Abnormal sac criteria

 An early normal intrauterine gestational sac often

can be identified transabdominally by 31 days GA
and can consistently be identified by 35 days GA.
To confidently diagnose an IUP, most
sonographers rely on the double decidual sac
(DDS) finding, which is not universally present
until the MSD is 10 mm (40 days GA) (Nyberg,
1983).
 Abnormal sac criteria
By transabdominal approach, size criteria that
unequivocally suggest an abnormal sac include
 failure to detect a DDS when the MSD is equal
to or greater than 10 mm,
 failure to detect a yolk sac when the MSD is
equal to or greater than 20 mm,
 failure to detect an embryo when the MSD is
equal to or greater than 25 mm (Nyberg, 1986).
 Abnormal sac criteria
Using vaginal ultrasound, a normal intrauterine
gestational sac can be detected reliably at 4-5
weeks GA, at which time the MSD approaches 5
mm. Using vaginal transducers, criteria that
suggest an abnormal sac include
 failure to detect a yolk sac when the MSD is 8
mm or greater, and
 failure to detect cardiac activity when the MSD
exceeds 16 mm (Levi, 1988)
 Visualizing an "empty"
gestational sac

 The earliest appearance for a normal sac is a

small fluid collection surrounded by high-
amplitude echoes embedded in the
decidualized endometrium. This appearance
has been termed the “intradecidual sac sign”
(IDSS)).
 Visualizing an "empty"
gestational sac

An "empty " gestational sac is the result of 1

of 3 entities:
 1) a normal early IUP,
 2) an abnormal IUP, or
 3) a pseudogestational sac in a patient
with an ectopic pregnancy.
 Using a vaginal approach, the mean diameter of
this sac exceeded 20 mm. Neither a yolk sac nor
embryo was visible. These findings are consistent
with a "blighted ovum
DDS yolk sac embryo

TAUS TAUS TAUS

MSD is MSD MSD

10 mm 20mm 25mm

transabdominally
 Note the irregular shape to this sac. In addition,
the choriodecidual reaction is somewhat thin. Not
surprisingly, this pregnancy failed.
 Growth rate
 In normal gestation, mean sac growth is 1.13
mm/day; in comparison, mean sac growth in
an abnormal intrauterine gestation is 0.70
mm/day (Nyberg, 1987).
 Based on these observations, abnormal sac
growth can be diagnosed confidently if the
gestational sac fails to grow by at least 0.6
mm/day.
 Choriodecidual appearance
This refers to the sonographic appearance of
the echoes that surround an early intrauterine
gestational sac. An abnormal appearance
includes a distorted sac shape;
 a thin (<2 mm), weakly echogenic, irregular
choriodecidual reaction;
 absence of the double decidual sac sign
when the MSD exceeds 10 mm
The Living Embryo and
threatened abortion
The Living Embryo and threatened
abortion
 The presence of an embryonic heartbeat is
highly reassuring. When visualized by Low
Resolution Abdominal sonography, more
than 90% of pregnancies continue
 Visualization by high resolution vaginal
sonography is associated with a 70%
continuance rate.
The Living Embryo and threatened
abortion
33% are lost With
bleeding

< 6 week.,
16% are lost if no
bleeding present
The Living Embryo and threatened
abortion
10% are lost With
bleeding

7-9 week

5 % are lost if no
bleeding present
The Living Embryo and threatened
abortion
4 % are lost With
bleeding

9-11 week

2% are lost if no
bleeding present
 conclusion
The prognosis for the
living embryo
improves as
gestation proceeds
 Visualizing a central cavity
complex

When the central cavity complex is abnormally

thickened (and often irregularly echogenic),
the differential diagnosis includes:
 intrauterine blood, retained products
following an spontaneous abortion,
 decidual changes secondary to an early but
not yet visible intrauterine pregnancy,
 or a decidual reaction from an ectopic
pregnancy.
 Degree of Confidence
 If certain findings are not observed at the
appropriate time, if the ultrasound findings are
equivocal, if the examination is technically
difficult, or if the sonographer is inexperienced,
caution is warranted.
 The embryo always should be given the
benefit of the doubt, and a follow-up
ultrasound examination should be performed
to obviate any risk of terminating a normal
intrauterine pregnancy.
 False Positives/Negatives
 Prior to visualizing the yolk sac, it is often not
possible to be certain if a small intrauterine
saclike structure is due to an early
intrauterine pregnancy (normal or abnormal),
or a pseudosac associated with an ectopic
pregnancy. This is because it may not be
possible to clearly identify the DSS. Under
these circumstances, a follow-up examination
should be performed if clinically feasible.
 False Positives/Negatives
 Occasionally, a subchorionic hemorrhage
may resemble a second intrauterine sac.
However, since most of these women are
bleeding, with careful scanning, the correct
diagnosis usually can be made. Whenever
uncertainty exists, perform a short interval
follow-up examination at 5-7 days