Certain U/S findings can be suggestive of a nonviable pregnancy. To add to the list above, additional findings concerning for EPF are: fetal bradycardia, expanded amnion sign, and yolk sac abnormalities (size >6 mm, abnormal location, number, or echogenicity).15,19,20 Importantly, both ACOG and the SRU state, “These are the radiologic criteria only and do not replace clinical judgment.” Other factors to account for are the risks of postponing diagnosis in medically complex patients, the patient’s desire to continue the pregnancy, or the patient’s desire to achieve 100% certainty prior to intervention. A discussion with the patient about the possible outcomes should be had, and should guide further diagnostic and clinical management.
Because assigning an estimated date of delivery is frequently challenging due to unknown/inaccurate LMP, most of the criteria in the chart are based on U/S findings and their changes over time rather than on gestational age. Thus the patient should be followed with serial hCG levels, and repeat U/S in 7–14 days. In addition, if no IUP is seen, the diagnosis of pregnancy of unknown location (PUL) is made and the patient should be told of the warning signs for ectopic pregnancy.
None of the authors report a conflict of interest to report with respect to the content of this article.
- Doubilet PM. Ultrasound evaluation of the first trimester. Radiol Clin North Am, 2014. 52(6):1191-9.
- Doubilet PM, et al. Diagnostic criteria for nonviable pregnancy early in the first trimester. Ultrasound Q, 2014. 30(1):3-9.
- Abdallah Y, et al. Gestational sac and embryonic growth are not useful as criteria to define miscarriage: a multicenter observational study. Ultrasound Obstet Gynecol, 2011. 38(5):503-9.
- Abdallah Y, et al. Limitations of current definitions of miscarriage using mean gestational sac diameter and crown-rump length measurements: a multicenter observational study. Ultrasound Obstet Gynecol, 2011. 38(5):497-502.
- Barnhart KT, et al. Symptomatic patients with an early viable intrauterine pregnancy: HCG curves redefined. Obstet Gynecol, 2004. 104(1):50-5.
- Wilcox AJ. Baird DD, Weinberg CR. Time of implantation of the conceptus and loss of pregnancy. N Engl J Med, 1999. 340(23):1796-9.
- Korevaar TIM, et al.,Reference ranges and determinants of total hCG levels during pregnancy: the Generation R Study. European Journal of Epidemiology, 2015. 30(9):1057-1066.
- Cervinski MA, et al. Qualitative point-of-care and over-the-counter urine hCG devices differentially detect the hCG variants of early pregnancy. Clin Chim Acta, 2009. 406(1-2): 81-5.
- Montagnana M, et al. Human chorionic gonadotropin in pregnancy diagnostics. Clin Chim Acta, 2011. 412(17-18):1515-20.
- Donald I. Clinical application of ultrasonic techniques in obstetrical and gynaecological diagnosis. J Obstet Gynaecol Br Emp, 1962. 69:1036.
- Brown DL, et al.,Diagnosis of early embryonic demise by endovaginal sonography. J Ultrasound Med, 1990. 9(11): p. 631-6.
- Pennell RG, et al. Prospective comparison of vaginal and abdominal sonography in normal early pregnancy. J Ultrasound Med, 1991. 10(2): p. 63-7.
- Doubilet PM, et al. Diagnostic criteria for nonviable pregnancy early in the first trimester. N Engl J Med, 2013. 369(15):1443-51.
- Bradley WG, Fiske CE, Filly RA. The double sac sign of early intrauterine pregnancy: use in exclusion of ectopic pregnancy. Radiology, 1982. 143(1):223-6.
- Hamza A, et al. Diagnostic Methods of Ectopic Pregnancy and Early Pregnancy Loss: a Review of the Literature. Geburtshilfe Frauenheilkd, 2016. 76(4):377-382.
- Goldstein I, et al. Evaluation of normal gestational sac growth: appearance of embryonic heartbeat and embryo body movements using the transvaginal technique. Obstet Gynecol, 1991. 77(6):885-8.
- Bree RL, et al. Transvaginal sonography in the evaluation of normal early pregnancy: correlation with HCG level. AJR Am J Roentgenol, 1989. 153(1):75-9.
- Chung K, Allen R. The use of serial human chorionic gonadotropin levels to establish a viable or a nonviable pregnancy. Semin Reprod Med, 2008. 26(5):383-90.
- Horrow MM. Enlarged amniotic cavity: a new sonographic sign of early embryonic death. AJR Am J Roentgenol, 1992. 158(2):359-62.
- Bromley B, et al. Small sac size in the first trimester: a predictor of poor fetal outcome. Radiology, 1991. 178(2):375-7.