Early Pregnancy Loss Differential Diagnoses

Updated: Jun 08, 2018
  • Author: Elizabeth E Puscheck, MD; Chief Editor: Richard Scott Lucidi, MD, FACOG  more...
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DDx

Diagnostic Considerations

Important considerations

Failure to diagnose correctly may occur in early pregnancy loss.. A presumed completed abortion may be an ectopic pregnancy with passage of clot in which the clot was thought to be tissue. Use caution, as missing an ectopic pregnancy can be a life-threatening situation. If uncertainty exists regarding whether the passed material is tissue or a clot, have a pathologist evaluate it prior to sending the patient out.

If a suction D&C is performed, then a known complication in a small percentage of cases is Asherman syndrome or intrauterine synechiae. This situation may cause amenorrhea, infertility, or miscarriage in these patients in the future. Be gentle with the sharp curettage after the suction, and, if there is difficulty, ultrasound guidance may be helpful. Do not forget that bleeding may be occurring due to DIC, which requires replacement of the missing factors.

Perforation of the uterus may occur if a suction D&C is performed. Pregnant uteri are softer than the unpregnant state, and it is easier to perforate. Uterine perforation may occlude itself naturally because the uterus is a muscle that can undergo contraction and place its own pressure on the site until the bleeding stops. However, uncontrolled internal bleeding from a uterine perforation may require additional surgery, either a laparoscopy or laparotomy to control the bleeding. Occasionally, a hysterectomy may be the last resort to control the bleeding, which would eliminate the patient's ability to conceive in the future. Unrecognized uterine perforations may lead to significant internal bleeding that could be a life threat. Observe patients closely after a D&C and listen when patients complain of unusual symptoms (eg, shoulder pain, unexpectedly significant abdominal pain).

Misdiagnosis of an early intrauterine pregnancy for an ectopic pregnancy and administering methotrexate inappropriately may occur if the physician is not familiar with the laboratory and ultrasonography department's discriminatory zone. Thinking about the patient's history and physical examination, differential diagnosis (including multiple gestations), the accuracy of the gestational age, the hCG level (and pattern of hCG levels if checked every 2 d), and ultrasonographic findings is very important to make an appropriate diagnosis. This is an area of rapidly growing malpractice in obstetrics and gynecology.

Misdiagnosis of an ectopic pregnancy as an incomplete or inevitable abortion can be a problem. In these cases, it is important to follow up on the pathology findings from the suction D&C. If one is uncertain, ask pathology to evaluate the specimen while one is still in the operating room and proceed to laparoscopy if no chorionic villi are found in the suction D&C specimen.

Other problems to be considered

Other conditions to consider in patients with early pregnancy loss include:

  • Abortion, incomplete

  • Abortion, inevitable

  • Acute appendicitis

  • Cervical polyps, ectropion, or malignancy

  • Ovarian torsion

  • Pregnancy, molar

  • Pregnancy, subchorionic hemorrhage

  • Vaginal/vulvar condylomata

Differential Diagnoses