A 33 yr woman with 8.4 weeks estimated gestational age with last menstrual period revealed following reports on transvaginal ultra-sonography:
1. Bulky uterus
2. Single gestation sac of about 5.43X4.62X3.34 cm size in uterine cavity.
3. Crown to rump length of embryo is 16.3 mm which correspond to 8.2 weeks of gestation.
4. Normal yolk sac seen in gestation sac.
5. Trophoblastic rim is normal in thickness and ecogenicity. A small anechoic area seen right laterally.
6. Gestation sac contains single embroyo without cardiac pulsations.
Pathology impression: finding suggstive of missed abortion. Minimal separation of membranes noted.
Physician recommend to undergo D&C (dilation and curettage). What would be the actual action to be taken under such circumstances i.e. D&C or wait for few weeks. Is such kind of sonography reports are always true.
Fetal viability is best determine by us evident by cardiac pulsation.
And this can be achievied with certainity after 6 weeks gestations.
Consumptive coagulopthy in missed aborton usually occur after the 4th weeks following fetal death. In the above case the best mangement is rescan after 1 to weeks as fetal death sonographically depends on the quality of machine and the skill of the operator.
Wait is the safe method for the above mentioned patient.
Con las medidas fetales citadas y latido negativao la conducta en nuestro centro seria ofrecer una evacuación uterina por via farmacologica o instrumental recomendando preferentemente la instrumantal. se haria un seguimiento de la coagulacion incluyendo el fibrinogeno dos veces en los siguientes siete dias.
viability of the fetus is determine by ultrasound evident of cardiac pulsation, from the 5th week of gestation so for above patient, repeat scan after 2 weeks to check for viability of the fetus
While waiting and re-scanning is probably safe, it is also unnecessary. Given the advanced size of the foetus, the lack of heartbeat is inconsistent with normal pregnancy and is diagnostic of nonviable pregnancy (missed abortion)
Diagnostic criteria for nonviable pregnancy early in the first trimester. N Engl J Med. 2013 Oct 10;369(15):1443-51.
Fetal viability is usually evident with cardiac pulsation on USS within 6-8weeks.
In this case the repeat scan can be done in another 7-10days to determine the viability.
The fear of bleeding disorder is low here as this more common after 4weeks of fetal demise.
Though fetal viability has been determined by US scan as early as 5 weeks in most centers, this diagnosis can delay up to 9-10 weeks in some due to challenges associated with the model of the equipment and the expertise of the operator. A repeat scan within a few days by another expert may reaffirm the diagnosis of missed abortion.
This is a very important diagnostic dilemma which we must all learn from. First, we must compare the gestational age based on her last menstrual period to the ultrasound gestational age. In this case, the disparity is just 2 days (8.4 weeks to 8.2 weeks). This difference is not enough to condemn the baby’s fate as missed abortion in spite of absent fetal heart rate; even though it is quite unusual and worrisome at this gestational age. A repeat scan should be done after 7 days preferably by two skilled operators before any further decision is made
It is not unreasonable to wait an additional week for a further confirmation scan should the patient prefer.
However, a diagnosis of a miscarriage can be made when there is no cardiac pulsation is seen on trans-vaginal ultrasound when the fetal crown crump length is greater than 7mm. The CRL in this case is 16mm which is well in excess of this cut-off and consistent with a diagnosis of missed miscarriage. It is therefore also reasonable to proceed with a same-day confirmation scan by a second sonographer and to directly book a D &C.
ref: https://rcpi-live-cdn.s3.amazonaws.com/wp-content/uploads/2016/05/1.-Ultrasound-Diagnosis-of-Early-Pregnancy-Loss.pdf
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