Benha Faculty of Medicine

1. Early Pregnancy Loss
A Simplified Ultrasound
Approach
Dr/ Ahmed Walid Anwar Morad
Professor Obstetrics & Gynecology
Benha Faculty of Medicine
2021

2.  Introduction (Terminology - incidence-
Diagnosis)
 Sequence of events in early
pregnancy by TVUS
 Criteria for early pregnancy loss
 Definite criteria
 Suspicious criteria
 Take home message

3. Viability
20
Weeks
Pregnancy
(Loss – Failure- Demise)
Death of the embryo or fetus
Introductio
n
‫؟؟؟‬

4.  Viability:
 Legal definition: Ability of the fetus to survive independently outside
the uterus.
 Loose definition: used by some
 Viable = alive (cardiac pulsation) especially in the 1st trimester.
 Miscarriage versus abortion ???
USA (ACOG) 20 gestational weeks 
WHO 22 gestational weeks
UK(RCOG) 24 gestational weeks
Developing countries 28 gestational weeks

5. Based on US: Pregnancy loss <20 weeks
Visualized pregnancy loss
(ASRM 2013)
Non-visualized pregnancy loss
(Kolte et al. (2014)
Confirmed by:
1. Ultrasound or
2. Histology
Based on:
1. ↓serum or urinary b-hCG levels &
2. Non-localization on ultrasound.
Diagnosi
s of
Demise
 Intrauterine ( Miscarriage)
1. Early 
2. Late
1. Biochemical pregnancy loss:
Causes
 Extra-uterine (Ectopic)
2. Resolved PUL
3. Treated PUL

6. Definition of Early pregnancy loss(EPL)
ASRM 2013
ACOG 2018
- Spontaneous pregnancy demise./
- “Nonviable, intrauterine pregnancy with either:
An empty gestational sac or
A gestational sac containing an embryo or fetus without
fetal heart activity
Criteria
Before 10 weeks of gestational
age (before 8th developmental
week)
Before 12 weeks and 6 days of
gestation
Timing

9. Incidence:
Spontaneous pregnancy 10%
ART: 30%
Increasing with advancing parental age.

10. Diagnosis of EPL= Puzzle of 3 Parts
Clinical B-HCG TVUS
Discriminatory
zone
Single
Measurement
(Doubling)
Trend of rise
(8wks/ 8-10wks)

11. Sequence of events in early
normal pregnancy by TVUS

12. Embryologic development in early pregnancy is quite
linear and follows a dependable fixed timetable.
Embryology Development Ultrasonography Finding

15. Key points
 In a woman with a positive beta-hCG, any intrauterine sac-like
fluid collection seen on ultrasound is highly likely to be a
gestational sac.
 In haemodynamically stable woman: If a definite IUP is not be
confirmed on sonography → repeat scanning and serial quantitative
beta-HCG are required, until either:
1. IUP is established,
2. Ectopic pregnancy is visualized, or

16. Timing of the sonographic evaluation is essential
in management, as too early evaluation is
likely to:
 False diagnosis a pregnancy of unknown
location or an intrauterine pregnancy of
uncertain viability.
 Inadvertent interventions.

17. TVUS diagnosis of IU early
pregnancy failure
Definite criteria
Suspicious
criteria
(Uncertain)
Diagnostic
Immediate treatment is
the role
Follow up & further
testing is the role
Criteria are from the Society of Radiologists in Ultrasound Multispecialty Consensus Conference on
Early First Trimester. Diagnosis of Miscarriage and Exclusion of a Viable Intrauterine Pregnancy,
October 2012

18. 4 Definitive Diagnostic Criteria for early IUP
Failure
2 Sized
Based
2 Time
Based

19. Definitive Diagnostic Criteria for early IUP
Failure
1) CRL≥ 7mm without
heartbeat
2) MSD ≥25mm without visible
embryo
PPV for IU pregnancy failure
100%
PPV for IU pregnancy failure
100%
2 Size Based
Criteria

20. Definitive criteria for early IUP Failure
2 Time Based
Criteria
4)
3)
Absence of embryo with heart-
beat
Recent Scan
≥ 11 days
≥ 14 days
Time interval
GS with YS
GS without YS
Initial scan

21. Definitive criteria for early IUP Failure
Additional criteria
Embryo
(Irrespective
CRL)
No cardiac activity:
-Initial scan
-Repeated scan≥ 7
days later
Stop of
previously
documented
cardiac activity
Not involved in:
Criteria are from the Society of Radiologists in Ultrasound Multispecialty Consensus Conference on Early First
Trimester
Diagnosis of Miscarriage and Exclusion of a Viable Intrauterine Pregnancy, October 2012.

23. Suspicious criteria for early IUP Failure
2 Size Based
Criteria

24. Suspicious criteria for early IUP Failure
3rd & 4th criteriaare similar to definitive criteria but less than 14-11days
4)
3)
Absence of embryo with heart-
beat
Recent Scan
7- 10 days
7-13 days
Time interval
GS with YS
GS without YS
Initial scan
2 Time Based
Criteria

25. Suspicious criteria for early IUP Failure

26. Suspicious criteria for early IUP Failure

27. Suspicious criteria for early IUP Failure
Visible embryo (regardless
CRL) surrounded by an
amnion (TVUS) with no
heartbeat.
9. Expanded amnion
sign:

28. Embryos with cardiac activity
Is there are Sonographic criteria for
increased risk of EPL?
Specific
Common
A. Fetus:
1. Embryonic bradycardia
2. CRL of 10% less than
expected for GA.
B. Placenta
1. A subchorionic hematoma.
2. Chorionic Bump.
1. Small gestational sac in
relation to crown-rump
length
2. A large yolk sac

29. Suspicious criteria
 The slower the embryonic or fetal heart rate,
the higher the risk of pregnancy loss.
 Assessing embryonic HR by M-mode during
early ultrasound is mandatory why ‫؟‬
1. A normal embryonic or fetal HR is reassuring
2. Bradycardia indicates a sonographic follow-
up.

2
1) Embryonic or fetal
bradycardia:
(Doubilet and Benson 2013)

30. Suspicious criteria
 Increased rate of pregnancy loss
1. Hematoma is large, associated with bleeding or the
patient is≥ 35 years. (Bennett et al., 1996)
2. Diagnosed before 8 weeks (19.6%). (Heller et al., 2018)
 A recent retrospective study → ↑risk of pregnancy loss
before 20 weeks gestation (7.5% vs. 4.9% P=.026)
however, when adjusting for patient age and bleeding, this
association was no longer significant. (Naert et al., 2019a)
 No increased risk of adverse outcome later in gestation→
Follow up sonography is recommended. (Naert et al., 2019b)
2) Subchorionic hematoma

31. Suspicious criteria
 Def: An irregular, convex bulge from the choriodecidual surface
into the first-trimester gestational sac, likely reflecting a
hematoma or necrotic decidua.
 Significance:
1. Before 11 weeks gestation→↑ increased risk of EPL.
2. After 11 weeks→ Clinically irrelevant
3. If identified in the pregnancy with normal in appearance & heart
rate, the live birth rate has been reported to be 83%.
4. No relationship between the volume of the chorionic bump or
bleeding per vagina and the risk of pregnancy loss. (Bromley
3) Chorionic Bump

32. Take Home Message
 TVUS order of embryonic structures appearance in
early pregnancy is essential in diagnosis of early IUP
failure.
 Although TVUS is a powerful tool in the diagnosis and
prediction of early pregnancy loss. It should be used in
combination with β-hCG and clinical history.
 Timing of the sonographic evaluation is essential in
management, as too early evaluation is likely to ↑false
diagnosis of EPL or PUL and increase non-
recommended interventions.

33. Take Home Message
 Sonographic Criteria with increased risk for EPL in
embryos in which cardiac activity should be considered
 Immediate treatment is the role when there are definitive
TVUS criteria for early nonviable IUP.
 Follow up for 7-14 days is the role when there are
suspicious TVUS criteria for IUP failure (Pregnancy of
uncertain viability)

34. References
1. Kolte AM, Bernardi LA, Christiansen OB, Quenby S, Farquharson RG, Goddijn M, Stephenson
MD; ESHRE Special Interest Group, Early Pregnancy. Terminology for pregnancy loss prior to
viability: a consensus statement from the ESHRE early pregnancy special interest group. Hum
Reprod. 2015 Mar;30(3):495-8. doi: 10.1093/humrep/deu299. Epub 2014 Nov 5. PMID: 25376455.
2. Datta, M. R. & Raut, A. Efficacy of first-trimester ultrasound parameters for prediction of early
spontaneous abortion. Int J Gynaecol Obstet 138, 325–330 (2017).
3. American College of Obstetricians and Gynecologists. Early pregnancy loss. Practice Bulletin No.
150. Obstet & Gynecol 2015; 125, 1258–1267. Retrieved February 15, 2018,
4. Pillai, R. N., Konje, J. C., Richardson, M., Tincello, D. G. & Potdar, N. Prediction of miscarriage in
women with viable intrauterine pregnancy—A systematic review and d iagnostic accuracy meta-
analysis. Eur J Obstet Gynecol Reprod Biol 220, 122–131 (2018).
5. Detti L, Francillon L, Christiansen ME, Peregrin-Alvarez I, Goeske PJ, Bursac Z, Roman RA. Early
pregnancy ultrasound measurements and prediction of first trimester pregnancy loss: A logistic
model. Sci Rep. 2020 Jan 31;10(1):1545. doi: 10.1038/s41598-020-58114-3. PMID: 32005925;
PMCID: PMC6994659.
6. Bromley B& Shipp TD. An imaging approach to early pregnancy failure. Contemporary OB/GYN
Journal, Vol 65 No 10 (2020)