1. LOGO
EARLY
PREGNANCY
LOSS
DILEMMAS
Dr. JYOTI BHASKAR
DR. SHARDA JAIN
Director of Lifecare IVF

2. Content
1
2
3
4
DEFINITIONS
ULTRASOUND
HCG INTERPRETATION
PREGNANCY OF UNKNOWN
LOCATION
5
ANTI D PROPHYLAXIS
6
MANAGEMENT

3. SOURCES
 Diagnosis and initial management in early
pregnancy of ectopic pregnancy and miscarriage
NICE clinical guideline 154, Dec 2012
 AEPU Guidelines 2007
 Management of Early Pregnancy Loss
Green Top Guideline No. 25 , 2006
 Rhesus D Prophylaxis, The Use of Anti-D
Immunoglobulin for (Green-top 22,2011)
 Lifecare Centre Experience

4. DEFINITIONS
 Change in terminology to MISCARRIAGE
Spontaneous/Threatened/Missed/Inevitable/
Complete/Incomplete/Recurrent
Miscarriage
Anembryonic / Blighted Ovum
Delayed / Silent Miscarriage

5.  Pregnancy of Unknown Location( PUL)
( 8-31% at first visit)
No signs of either Intrauterine or extrauterine
pregnancy or RPOC on TVS in a women with
positive pregnancy test.
 Pregnancy of Uncertain Viability ( PUV)
( 10% at first visit)
Intrauterine GS < 20 mm with No YS or FP
or
Fetal echo < 7mm with No CA

6. ULTRASOUND
 TVS is the method of choice
 If unacceptable, do TAS and explain the
limitations of this method of scanning
 Diagnosis of miscarriage using 1 ultrasound
scan cannot be guaranteed to be 100%
accurate
Diagnosis and initial management in early pregnancy of ectopic pregnancy and
miscarriage
NICE clinical guideline 154, December 2012

7. What to expect in USG
5 weeks
4 weeks
6 weeks

8. GS
GS < 20mm
No YS
GS < 25 mm
No Fetal Pole
Rescan after 1 week
GS >25mm
No embryo
MISSED MISCARRIAGE
Rescan after 1 week
Second opinion

9. CRL
CRL < 7MM
NO CA
PUV
Rescan after 1 week
CRL > 7MM
NO CA
EARLY FETAL LOSS
MISSED MISCARRIAGE
Rescan after 1 week
Second opinion

10. ET
< 15MM
> 15MM
HOMOGENOUS MASS
IN CAVITY
H.MOLE
SERUM B HCG
COMPLETE
MISCARRIAGE
INCOMPLETE
MISCARRIAGE
EXCLUDE PREGNANCY OF UNKNOWN LOCATION/ ECTOPIC

11. UNDERSTANDIING HCG MEASUREMENTS
USEFUL IN
 Screening in women at high risk of ectopic
pregnancy
 Monitoring during expectant management
or medical management of women with
pregnancy of unknown location and ectopic
pregnancy
 Evaluation of conservative surgical
treatment of ectopic pregnancy

12. HCG DOUBLING TIME
 It refers to the time taken for the hCG
level to double its original value
 Serum hCG levels double approximately
every two days in early (<8 weeks)
 a lesser increase (<66% over 48 hours) is
associated with ectopic pregnancy and
miscarriage.

13. CAUTION
 15% of normal pregnancies will have
abnormal doubling time and 13% of
ectopic pregnancies will have a normal
doubling time
 In multiple pregnancies and
heterotropic pregnancies the level of
hCG on D2 would be a little higher

14. DISCRIMINATORY HCG ZONE
 Level of hCG above which the gestational sac
of an intrauterine pregnancy should be visible
on ultrasound.
 It usually lies between 1000 – 2400IU/L.
 Depends on three factors:
i) hCG assay
ii) quality of ultrasound
iii) the experience of the person Performing
USG

15. BETA HCG INTERPRETATION
Serum B HCG at
0 and 48 hrs
> 66% increase
IUP
> 66% increase or
< 21-35% decrease
? Ectopic
Pregnancy
>21-35% decrease
? Failing PUL
Miscarriage

16. Pregnancy test positive
+ TVS
Inconclusive result
(No evidence of IUP or EP)
Serum HCG measurements every 2-3 days
Rising (doubling)
Falling
Repeat TVS when hCG >1000 IU/L
Complete miscarriage
No further scans are necessary
Follow up until hCG <20 IU/L
IUP
No further hCG assays
Rescan in one week
Suboptimal rise/plateauing/falling slowly after 2-3 measurements
TVS
EP
PUL
Non-viable IUP

17. Role of serum progesterone
Serum progesterone
< 20 nmol/L
PPV > 95% to predict
Pregnancy failure
(Banerjee et al., 2001)
Viable IUPs reported with
levels < 16nmol/L
>60 nmol/L
‘Strongly’
associated with
viable pregnancies
Discriminative capacity insufficient
to diagnose ectopic pregnancy with
certainty
(Mol et al., 1998)
Good at predicting viability but not location

18. RHESUS ANTI D PROPHYLAXIS
 THREATENED MISCARRIAGE
- all > 12 weeks
- if bleeding persists , given at 6 weekly
interval ( RCOG recommendation )
 Prudent to administer anti-D as gestation
approaches 12 weeks
1. where bleeding is heavy or repeated
2. where there is associated abdominal pain
(RCOG Grade C recommendation)

19. Spontaneous Miscarriage
 Given to all non-sensitised RhD negativeWith spontaneous complete or
incomplete miscarriage after 12
weeks of pregnancy
(RCOG Grade B recommendation)
Before 12 weeks not recommended as risk of
immunisation is negligible. (RCOG Grade C recommendation).

20. SPECIAL SITUATIONS -- GIVEN
ERPC OR TOP
Therapeutic termination of pregnancy,
whether by surgical or medical
methods, regardless of gestational
age (RCOG Grade B recommendation).
ECTOPIC PREGNANCY
confirmed or suspected ectopic
pregnancy
(RCOG Grade B recommendation).

21. DO NOT GIVE
Threatened
Spontaneous
Complete
H. MOLE
<12 weeks
NO ANTI D
PROPHYLAXIS

22. DOSAGE OF ANTI D
•
UPTO 20 WEEKS -- 250 IU ( 50 ug)
• MORE THAN 20 WEEKS – 500 IU ( 100 ug)
Available in India
1. 50 ug – Microhogam UF
2. 100 ug - Vinobulin
3. 300 ug -- Predominantly

23. MEDICAL MANAGEMENT –
Method of Choice
Missed miscarriage
Incomplete miscarriage
NO MIFEPRISTONE
VAGINAL MISOPROSTOL
800 MG
600 MG

24. Surgical Management
 Only in
•
•
•
•
Persistent excessive bleeding
Haemodynamically unstable
Infected retained tissue
Suspected Gestational trophoblastic tissue

25. Surgical Management
 Vaccum Aspiration – Method of choice
 Prior Prostaglandin administration
 If infection suspected – delay intervention
for 12 hrs for I/V antibiotic

26. TAKE HOME MESSAGE
 Understand changing management trends
 Moved Towards
• Treatment on Outpatient basis
• Refined and Indicated Diagnostic techniques
• Patient centred Therapeutic Interventions
 Interpret USG and HCG results wisely and reach
a diagnosis
 Always be on look out for ectopic pregnancy and
PUL

27.  Follow the latest protocols for Anti D
prophylaxis in early pregnancy
 Medical management is the treatment of
choice
 The approach has to be patient centred.

28. Pregnancy of Unknown Location
 Expectant management suitable for
majority of women
 No consensus on appropriate intervention
but no routine role for curettage
 Serum hCG and progesterone levels
useful, but no role for single hCG
measurement

29. &
ADDRESS
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CONTACT US
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www.lifecareivf.com
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