eMedicine Specialties > Obstetrics and Gynecology > General Gynecology
First-Trimester Pregnancy Loss: Differential Diagnoses & Workup
Updated: Jun 25, 2006
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Differential Diagnoses
| Abortion | Hematologic Disease and Pregnancy |
| Adnexal Tumors | Ovarian Cysts |
| Amenorrhea, Secondary | Threatened Abortion |
| Cervical Cancer | von Willebrand Disease |
| Cervical Ripening | |
| Cervicitis |
Other Problems to Be Considered
Abortion, incomplete
Abortion, inevitable
Acute appendicitis
Cervical polyps, ectropion, or malignancy
Ovarian torsion
Pregnancy, molar
Pregnancy, subchorionic hemorrhage
Vaginal/vulvar condylomata
Workup
Laboratory Studies
- Complete blood count (CBC) with differential, beta-hCG, blood type and screen (possible crossmatch), possible DIC profile, and urinalysis
- CBC will help document the amount of blood loss and whether anemia is present. If the hemoglobin and hematocrit are very low and the patient is symptomatic then transfusions would be warranted. The CBC also will provide evidence regarding an infection, which, in the case of infection, would yield an elevated white blood cell count and a left shift on differential.
- Beta-hCG is important to confirm the pregnancy and distinguish it from dysfunctional uterine bleeding or bleeding from another etiology. The hCG level is also important to help distinguish a complete abortion from a threatened abortion or ectopic pregnancy. If the hCG level is above 1500-2000 mIU/mL, then transvaginal ultrasonography should detect a viable intrauterine pregnancy. A level over 3000 mIU/mL should enable one to visualize a viable intrauterine pregnancy by transabdominal ultrasonography. If the values are so elevated, the cervical canal is closed, and the patient's history is consistent with passing tissue (which a physician has confirmed), then an empty uterus on ultrasonography is consistent with a completed abortion. However, if the hCG level is elevated, no history of passing tissue is present, and the ultrasonography demonstrates an empty uterus, one must assume that an ectopic pregnancy is present until proven otherwise. Low hCG levels (ie, <200 mIU/mL) may make the diagnosis more difficult. Observation and monitoring the hCG levels every few days may be an option if the patient is stable and not complaining of pain. If these low hCG levels plateau and fall, the patient will likely miscarry or have a tubal abortion on her own. However, if the values rise, then follow-up ultrasonography is necessary to determine whether an intrauterine pregnancy or an ectopic pregnancy is present and subsequent appropriate management is necessary. The hCG level should rise about 60% every 2 days during the early first trimester.
- Blood type and screen (possible crossmatch) is important to determine whether treatment with RhoGAM is appropriate. An Rh-negative woman should receive RhoGAM within 72 hours of miscarriage or ectopic pregnancy to avoid the possibility that the pregnancy has exposed the patient to a positive antigen. If the father of the baby also is Rh negative then the patient can forego the immunoglobulin therapy. It also is important in cases where transfusions are necessary.
- DIC profile is necessary only in those cases with significant bleeding. The DIC profile usually consists of a platelet count, fibrinogen level, prothrombin time (PT), and activated partial prothrombin time (aPTT). When significant bleeding occurs and the patient is consuming these factors faster then she can make them, then the initiating event needs to be treated (ie, D&C, hysterectomy) and platelets, coagulation factors (usually administered in the form of fresh frozen plasma or cryoprecipitate), or fibrinogen in addition to packed red blood cells may need to be replaced when transfusing a patient. Whole blood may be transfused as another alternative.
- Urinalysis is important to rule out a urinary tract infection. Pregnant women are prone to urinary tract infections due to the progesterone effect on the smooth muscle of the ureters, which causes mild physiologic hydroureters. A cystitis or renal stone also could be present with bleeding but from a urinary source.
Imaging Studies
- Ultrasound of the pelvis using a vaginal probe to rule out an ectopic pregnancy, retained products of conception, hematometra, or other etiologies: Once the discriminatory level is passed, the ultrasound is fairly reliable. Perform other imaging studies as needed.
Procedures
- If the diagnosis truly is a complete abortion, then no further procedures are needed.
More on First-Trimester Pregnancy Loss |
| Overview: First-Trimester Pregnancy Loss |
 Differential Diagnoses & Workup: First-Trimester Pregnancy Loss |
| Treatment & Medication: First-Trimester Pregnancy Loss |
| Follow-up: First-Trimester Pregnancy Loss |
| References |
| « Previous Page | Next Page » |
References
ACOG practice bulletin. Medical management of tubal pregnancy. Number 3, December 1998. Clinical management guidelines for obstetrician- gynecologists. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet. Apr 1999;65(1):97-103. [Medline].
Chipchase J, James D. Randomised trial of expectant versus surgical management of spontaneous miscarriage. Br J Obstet Gynaecol. Jul 1997;104(7):840-1. [Medline].
Chung TK, Cheung LP, Sahota DS, et al. Spontaneous abortion: short-term complications following either conservative or surgical management. Aust N Z J Obstet Gynaecol. Feb 1998;38(1):61-4. [Medline].
Creinin MD, Schwartz JL, Guido RS, Pymar HC. Early pregnancy failure--current management concepts. Obstet Gynecol Surv. Feb 2001;56(2):105-13. [Medline].
Geyman JP, Oliver LM, Sullivan SD. Expectant, medical, or surgical treatment of spontaneous abortion in first trimester of pregnancy? A pooled quantitative literature evaluation. J Am Board Fam Pract. Jan-Feb 1999;12(1):55-64. [Medline].
Herbst AL, Mishell DR, Stenchever MA, Droegemueller W, eds. Comprehensive Gynecology. St. Louis, Mo:. Mosby-Year Book;1992:445-453.
Hurd WW, Whitfield RR, Randolph JF Jr, et al. Expectant management versus elective curettage for the treatment of spontaneous abortion. Fertil Steril. Oct 1997;68(4):601-6. [Medline].
Jurkovic D, Ross JA, Nicolaides KH. Expectant management of missed miscarriage. Br J Obstet Gynaecol. Jun 1998;105(6):670-1. [Medline].
Kalousek DK. Clinical significance of morphologic and genetic examination of spontaneously aborted embryos. Am J Reprod Immunol. Feb 1998;39(2):108-19. [Medline].
Keith SC, London SN, Weitzman GA. Serial transvaginal ultrasound scans and beta-human chorionic gonadotropin levels in early singleton and multiple pregnancies. Fertil Steril. May 1993;59(5):1007-10. [Medline].
Nielsen S, Hahlin M. Expectant management of first-trimester spontaneous abortion. Lancet. Jan 14 1995;345(8942):84-6. [Medline].
Scroggins KM, Smucker WD, Krishen AE. Spontaneous pregnancy loss: evaluation, management, and follow-up counseling. Prim Care. Mar 2000;27(1):153-67. [Medline].
Weeks A, Alia G, Blum J, et al. A randomized trial of misoprostol compared with manual vacuum aspiration for incomplete abortion. Obstet Gynecol. Sep 2005;106(3):540-7.
Zhang J, Gilles JM, Barnhart K, et al. A comparison of medical management with misoprostol and surgical management for early pregnancy failure. N Engl J Med. Aug 25 2005;353(8):761-9.
Further Reading
Keywords
first-trimester pregnancy loss, miscarriage, spontaneous abortion, abortion, pregnancy loss, voluntary pregnancy termination, pregnancy termination, induced pregnancy termination, pregnancy complications, spontaneous complete abortion, ectopic pregnancy, incomplete abortion, inevitable abortion
