Pregnancy of Unknown Location & Early Pregnancy Loss
Presented by: Dr Robin Clouston
- Ruling out ectopic pregnancy is a critical issue in evaluation of the symptomatic patient in early pregnancy
- In women presenting to ED with abdominal pain or pv bleeding, prevalence of ectopic as high as 13%
- Well known sequelae of missed ectopic
- Rupture, tubal infertility, possible death
- Sequelae of false positive diagnosis of ectopic
- Termination of viable, desired pregnancy
Sonographic findings in Ectopic
- Adnexal mass
- Simple adnexal cyst – low probability ectopic if < 3mm (5%)
- Complex adnexal mass – high probability ectopic (90%)
- Most common location: ampullary or isthmic portion of fallopian tube (95% of ectopics)
- Isolated free fluid in the pelvis
- Rarely the only sonographic finding
- Pseudogestational sac – seen in at most 10% ectopic
- Normal scan – 15 to 25%
Utility of US with low βHCG
- ACEP recommends:
“Proceed to transvaginal ultrasonogaphy in symptomatic patients with βHCG less than 1000.”
- Comprehensive transvaginal ultrasonography has a moderate sensitivity to detect IUP with βHCG < 1000
- 40 to 67% sensitive
- For patients whose final diagnosis is ectopic:
- When βHCG < 1000, TVUS had 86 to 92% sensitivity to detect findings suggestive of ectopic
Safety of Discharge
- NJEM 2013:3
- there is limited risk in taking a few extra days to make a definitive diagnosis in a woman with a pregnancy of unknown location who has no signs or symptoms of rupture and no ultrasonographic evidence of ectopic pregnancy.
- Progression of hCG values over a period of 48 hours provides valuable information:13
- If failure to fall by 15%
- And failure to rise by 55%
- …most likely diagnosis is ectopic pregnancy
Morin L et al. Ultrasound Evaluation of First Trimester Complications of Pregnancy. J Obstet Gynaecol Can 2016;38(10):982-988
A reasonable approach
In the pregnant patient with vaginal bleeding and / or abdominal pain:
- Always perform bedside US to establish ?definitive IUP
- Do not rule out ectopic pregnancy in patients with empty uterus and βHCG < 1000
- Do obtain a comprehensive TVUS when bedside US does not confirm IUP regardless of βHCG
In the pregnant patient with vaginal bleeding and / or abdominal pain:
- When TVUS is delayed or remains non-diagnostic, involve obstetrician to aid in risk stratification and management
- Reliable, hemodynamically stable patients may be discharged with follow up
- Expedited TVUS (next day)
- Repeat βHCG in 48h
Take Home Points
- Do obtain a comprehensive TVUS when bedside US does not confirm IUP regardless of βHCG
- Do not rule out ectopic pregnancy in patients with empty uterus and βHCG < 1000
- Clinical judgment: safe discharge planning vs admission
- Low threshold to involve Obs-Gyn for these cases
- Early pregnancy loss is diagnosed by US when:
- CRL >/= 7mm with no FRH
- Mean sac diameter >/= 25mm and no embryo
- Expectant, medical and surgical management are equally effective and safe in treatment of EPL
- Patient preference may guide decision making
