Early Pregnancy Loss Workup
- Author: Elizabeth E Puscheck, MD; Chief Editor: Richard Scott Lucidi, MD, FACOG more...
Complete blood count (CBC) with differential
A CBC will help document the amount of blood loss and whether anemia is present. If the hemoglobin and hematocrit are very low and the patient is symptomatic then transfusions would be warranted. The CBC also will provide evidence regarding an infection, which, in the case of infection, would yield an elevated white blood cell count and a left shift on differential.
Beta-hCG is important to confirm the pregnancy and distinguish it from dysfunctional uterine bleeding or bleeding from another etiology. The hCG level is also important to help distinguish a complete abortion from a threatened abortion or ectopic pregnancy.
If the hCG level is above 1500-2000 mIU/mL, then transvaginal ultrasonography should detect a viable intrauterine pregnancy. A level over 3000 mIU/mL should enable one to visualize a viable intrauterine pregnancy by transabdominal ultrasonography. If the values are so elevated, the cervical canal is closed, and the patient's history is consistent with passing tissue (which a physician has confirmed), then an empty uterus on ultrasonography is consistent with a completed abortion. However, if the hCG level is elevated, no history of passing tissue is present, and the ultrasonography demonstrates an empty uterus, one must assume that an ectopic pregnancy is present until proven otherwise.
Low hCG levels (ie, < 200 mIU/mL) may make the diagnosis more difficult. Observation and monitoring the hCG levels every few days may be an option if the patient is stable and not complaining of pain. If these low hCG levels plateau and fall, the patient will likely miscarry or have a tubal abortion on her own. However, if the values rise, then follow-up ultrasonography is necessary to determine whether an intrauterine pregnancy or an ectopic pregnancy is present and subsequent appropriate management is necessary. The hCG level should rise at least 53% every 2 days during the early first trimester.
Blood type and screen
Blood type and screen (possible crossmatch) is important to determine whether treatment with RhoGAM is appropriate. An Rh-negative woman should receive RhoGAM within 72 hours of miscarriage or ectopic pregnancy to avoid the possibility that the pregnancy has exposed the patient to a positive antigen. If the father of the baby is also Rh negative then the patient can forego the immunoglobulin therapy. It is also important in cases where transfusions are necessary.
Possible DIC profile
A DIC profile is necessary only in those cases with significant bleeding. The DIC profile usually consists of a platelet count, fibrinogen level, prothrombin time (PT), and activated partial prothrombin time (aPTT). When significant bleeding occurs and the patient is consuming these factors faster then she can make them, then the initiating event needs to be treated (ie, D&C, hysterectomy) and platelets, coagulation factors (usually administered in the form of fresh frozen plasma or cryoprecipitate), or fibrinogen in addition to packed red blood cells may need to be replaced when transfusing a patient. Whole blood may be transfused as another alternative.
Urinalysis is important to rule out a urinary tract infection. Pregnant women are prone to urinary tract infections due to the progesterone effect on the smooth muscle of the ureters, which causes mild physiologic hydroureters. A cystitis or renal stone also could be present with bleeding but from a urinary source.
Ultrasonography of the pelvis using a vaginal probe should be performed to rule out an ectopic pregnancy, retained products of conception, hematometra, or other etiologies. Once the discriminatory level is passed, the ultrasound is fairly reliable as long as it is taken within the clinical scenario.
Guidelines for assessing prenatal viability
In October 2013, the Society of Radiologists in Ultrasound published new guidelines on using ultrasonography to assess prenatal viability.[20, 21] The guidelines are designed to help avoid the possibility of physicians causing inadvertent harm to a potentially normal pregnancy.
Diagnostic criteria for nonviability include the following:
A crown–rump length of ≥7 mm and no heartbeat
A mean sac diameter of ≥25 mm and the absence of an embryo
The absence of an embryo with heartbeat ≥2 weeks following a scan that showed a gestational sac with no yolk sac
The absence of an embryo with heartbeat ≥11 days following a scan that showed a gestational sac with a yolk sac
Findings that are suspicious for, but not diagnostic of, a pregnancy failure include the following:
A crown–rump length of < 7 mm and no heartbeat
A mean sac diameter of 16–24 mm and the absence of an embryo
The absence of an embryo with heartbeat 7–13 days following a scan that showed a gestational sac with no yolk sac
The absence of an embryo with heartbeat 7–10 days following a scan that showed a gestational sac with a yolk sac
The absence of an embryo ≥6 wk after the last menstrual period
An empty amnion
An enlarged yolk sac (>7 mm)
A small gestational sac in relation to the embryo size (< 5 mm difference between the mean sac diameter and the crown–rump length)
Presence of one or more of these findings should prompt further investigation into the pregnancy's viability.
If the diagnosis truly is a complete abortion, then no further procedures are needed.
If the diagnosis is unclear and there is fluid in the cul de sac, then a culdocentesis can be performed. This procedure is one where a needle with 10-20 mL syringe attached is placed into the posterior cul de sac through the vagina and the fluid is aspirated. If the fluid consists of nonclotting blood, then a ruptured ectopic pregnancy must be considered. This technique is not used often.
Alternatively, if the diagnosis is unclear, but normal early pregnancy has been excluded, a diagnostic D&C may be performed. In this situation, the specimen is sent for pathologic evaluation and, if chorionic villi are found, then an intrauterine pregnancy demise is confirmed. No further treatment is needed beyond the suction D&C. However, if no chorionic villi are found, then one needs to presume that an ectopic pregnancy is present and initiate appropriate treatment.
Pathology results from specimen sent from an early pregnancy (either from D&C for incomplete abortion or from ectopic pregnancy) should reveal chorionic villi.
Cengiz H, Dagdeviren H, Kanawati A, et al. Ischemia-modified albumin as an oxidative stress biomarker in early pregnancy loss. J Matern Fetal Neonatal Med. 2015 Sep 18. 1-4. [Medline].
Barnhart KT, Katz I, Hummel A, Gracia CR. Presumed diagnosis of ectopic pregnancy. Obstet Gynecol. 2002 Sep. 100(3):505-10. [Medline].
Condous G, Kirk E, Lu C, et al. There is no role for uterine curettage in the contemporary diagnostic workup of women with a pregnancy of unknown location. Hum Reprod. 2006 Oct. 21(10):2706-10. [Medline].
Calleja-Agius J, Jauniaux E, Pizzey AR, Muttukrishna S. Investigation of systemic inflammatory response in first trimester pregnancy failure. Hum Reprod. 2011 Nov 29. [Medline].
Nelson DB, Hanlon AL, Wu G, Liu C, Fredricks DN. First trimester levels of BV-associated bacteria and risk of miscarriage among women early in pregnancy. Matern Child Health J. 2015 Dec. 19 (12):2682-7. [Medline].
Giakoumelou S, Wheelhouse N, Cuschieri K, Entrican G, Howie SE, Horne AW. The role of infection in miscarriage. Hum Reprod Update. 2015 Sep 19. [Medline].
Arck PC, Rucke M, Rose M, et al. Early risk factors for miscarriage: a prospective cohort study in pregnant women. Reprod Biomed Online. 2008 Jul. 17(1):101-13. [Medline].
Maconochie N, Doyle P, Prior S, Simmons R. Risk factors for first trimester miscarriage--results from a UK-population-based case-control study. BJOG. 2007 Feb. 114(2):170-86. [Medline].
Gracia CR, Sammel MD, Chittams J, Hummel AC, Shaunik A, Barnhart KT. Risk factors for spontaneous abortion in early symptomatic first-trimester pregnancies. Obstet Gynecol. 2005 Nov. 106(5 Pt 1):993-9. [Medline].
Nakhai-Pour HR, Perrine B, Sheehy O, Berard A. Use of nonaspirin nonsteroidal anti-inflammatory drugs during pregnancy and the risk of spontaneous abortion. CMAJ. September 6, 2011. [Full Text].
Hahn KA, Hatch EE, Rothman KJ, et al. Body Size and Risk of Spontaneous Abortion among Danish Pregnancy Planners. Paediatr Perinat Epidemiol. 2014 Sep. 28(5):412-23. [Medline].
Clifford K, Rai R, Regan L. Future pregnancy outcome in unexplained recurrent first trimester miscarriage. Hum Reprod. 1997 Feb. 12(2):387-9. [Medline].
Liddell HS, Pattison NS, Zanderigo A. Recurrent miscarriage--outcome after supportive care in early pregnancy. Aust N Z J Obstet Gynaecol. 1991 Nov. 31(4):320-2. [Medline].
Stray-Pedersen B, Stray-Pedersen S. Etiologic factors and subsequent reproductive performance in 195 couples with a prior history of habitual abortion. Am J Obstet Gynecol. 1984 Jan 15. 148(2):140-6. [Medline].
Chang J, Elam-Evans LD, Berg CJ, et al. Pregnancy-related mortality surveillance--United States, 1991--1999. MMWR Surveill Summ. 2003 Feb 21. 52(2):1-8. [Medline].
O’Riordan M. Pregnancy loss associated with a later risk of atherosclerosis. March 29, 2013. Available at http://www.medscape.com/viewarticle/781681.
Ranthe MF, Andersen EA, Wohlfarht J, Bundgaard H, Melbye M, Boyd HA. Pregnancy Loss and Later Risk of Atherosclerotic Disease. Circulation. 2013 Mar 27. [Medline].
Practice Committee of American Society for Reproductive Medicine. Medical treatment of ectopic pregnancy. Fertil Steril. 2008 Nov. 90(5 Suppl):S206-12. [Medline].
Lewis R. First Do No Harm: Guidelines Define a Nonviable Pregnancy. Medscape Medical News. Available at http://www.medscape.com/viewarticle/812346. Accessed: October 15, 2013.
Doubilet PM, Benson CB, Bourne T, Blaivas M. Diagnostic Criteria for Nonviable Pregnancy Early in the First Trimester. N Engl J Med. 2013 Oct 10. 369(15):1443-1451. [Medline].
Weeks A, Alia G, Blum J, et al. A randomized trial of misoprostol compared with manual vacuum aspiration for incomplete abortion. Obstet Gynecol. 2005 Sep. 106(3):540-7. [Medline].
Zhang J, Gilles JM, Barnhart K, Creinin MD, Westhoff C, Frederick MM. A comparison of medical management with misoprostol and surgical management for early pregnancy failure. N Engl J Med. 2005 Aug 25. 353(8):761-9. [Medline].
Lee SK, Kim JY, Han AR, et al. Intravenous immunoglobulin G improves pregnancy outcome in women with recurrent pregnancy losses with cellular immune abnormalities. Am J Reprod Immunol. 2015 Oct 29. [Medline].
Luna RL, Nunes AK, Oliveira AG, et al. Sildenafil (Viagra) blocks inflammatory injury in LPS-induced mouse abortion: A potential prophylactic treatment against acute pregnancy loss?. Placenta. 2015 Oct. 36 (10):1122-9. [Medline].
[Guideline] American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 94: Medical management of ectopic pregnancy. Obstet Gynecol. 2008 Jun. 111(6):1479-85. [Medline]. [Full Text].
Wahabi HA, Fayed AA, Esmaeil SA, Al Zeidan RA. Progestogen for treating threatened miscarriage. Cochrane Database Syst Rev. 2011 Dec 7. 12:CD005943. [Medline].
Boyle FM, Mutch AJ, Barber EA, Carroll C, Dean JH. Supporting parents following pregnancy loss: a cross-sectional study of telephone peer supporters. BMC Pregnancy Childbirth. 2015 Nov 9. 15:291. [Medline].
[Guideline] ACOG practice bulletin. ACOG practice bulletin. Medical management of tubal pregnancy. Number 3, December 1998. Clinical management guidelines for obstetrician-gynecologists. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet. 1999 Apr. 65(1):97-103. [Medline].
Chipchase J, James D. Randomised trial of expectant versus surgical management of spontaneous miscarriage. Br J Obstet Gynaecol. 1997 Jul. 104(7):840-1. [Medline].
Chung TK, Cheung LP, Sahota DS, Haines CJ, Chang AM. Spontaneous abortion: short-term complications following either conservative or surgical management. Aust N Z J Obstet Gynaecol. 1998 Feb. 38(1):61-4. [Medline].
Creinin MD, Schwartz JL, Guido RS, Pymar HC. Early pregnancy failure--current management concepts. Obstet Gynecol Surv. 2001 Feb. 56(2):105-13. [Medline].
Geyman JP, Oliver LM, Sullivan SD. Expectant, medical, or surgical treatment of spontaneous abortion in first trimester of pregnancy? A pooled quantitative literature evaluation. J Am Board Fam Pract. 1999 Jan-Feb. 12(1):55-64. [Medline].
Hurd WW, Whitfield RR, Randolph JF Jr, Kercher ML. Expectant management versus elective curettage for the treatment of spontaneous abortion. Fertil Steril. 1997 Oct. 68(4):601-6. [Medline].
Jurkovic D, Ross JA, Nicolaides KH. Expectant management of missed miscarriage. Br J Obstet Gynaecol. 1998 Jun. 105(6):670-1. [Medline].
Kalousek DK. Clinical significance of morphologic and genetic examination of spontaneously aborted embryos. Am J Reprod Immunol. 1998 Feb. 39(2):108-19. [Medline].
Katz VL, Lentz G, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby Elsevier; 2007.
Keith SC, London SN, Weitzman GA, O'Brien TJ, Miller MM. Serial transvaginal ultrasound scans and beta-human chorionic gonadotropin levels in early singleton and multiple pregnancies. Fertil Steril. 1993 May. 59(5):1007-10. [Medline].
Nielsen S, Hahlin M. Expectant management of first-trimester spontaneous abortion. Lancet. 1995 Jan 14. 345(8942):84-6. [Medline].
Scroggins KM, Smucker WD, Krishen AE. Spontaneous pregnancy loss: evaluation, management, and follow-up counseling. Prim Care. 2000 Mar. 27(1):153-67. [Medline].
van Veen TR, Haeri S, Baker AM. Teen pregnancy: are pregnancies following an elective termination associated with increased risk for adverse perinatal outcomes?. J Pediatr Adolesc Gynecol. 2015 Dec. 28 (6):530-2. [Medline].
Marko EK, Buery-Joyner SD, Sheridan MJ, Nieves K, Khoury AN, Dalrymple JL. Structured teaching of early pregnancy loss counseling. Obstet Gynecol. 2015 Oct. 126 suppl 4:1S-6S. [Medline].