What would an ultrasound show immediately after a miscarriage with no bleeding?

From the Guidelines

An ultrasound immediately after a miscarriage with no bleeding would typically show an intrauterine gestational sac that appears abnormal, with no fetal heartbeat or fetal pole development, as indicated by the most recent and highest quality study 1. The healthcare provider might observe an empty gestational sac, a sac with a yolk sac but no embryo, or an embryo without cardiac activity.

• The ultrasound may also reveal a thickened endometrial lining containing pregnancy tissue that hasn't yet been expelled, which is known as a missed or silent miscarriage.
• The dimensions of the gestational sac or embryo might be smaller than expected for the gestational age.
• Additionally, the ultrasound might show decreased blood flow to the pregnancy when Doppler imaging is used. These findings help healthcare providers confirm that a miscarriage has occurred even though the body hasn't yet begun the physical process of expelling the pregnancy tissue, which explains the absence of bleeding. Following such an ultrasound diagnosis, your provider will discuss management options including expectant management (waiting for natural passage), medication to help complete the miscarriage, or a surgical procedure such as dilation and curettage (D&C) 1. It's essential to note that the absence of bleeding does not necessarily indicate a normal pregnancy, and an ultrasound is crucial in confirming the diagnosis of a miscarriage 1. The American College of Radiology Appropriateness Criteria and other guidelines emphasize the importance of ultrasound in evaluating first-trimester vaginal bleeding and suspected miscarriage 1. In the context of real-life clinical medicine, it's crucial to prioritize caution and consider the potential risks and benefits of each management option, taking into account the individual patient's circumstances and medical history 1.

From the Research

Ultrasound Findings After Miscarriage

• An ultrasound immediately after a miscarriage with no bleeding may show various findings, including:
  • Hyperechoic material within the endometrial cavity, which is a strong predictor of retained products of conception (RPOC) 2
  • Endometrial thickness, although this measurement is not a reliable predictor of RPOC 3
  • A gestational sac or space-occupying collection, which can indicate retained products of conception 4
• The absence of hyperechoic material and vaginal bleeding makes RPOC extremely unlikely 2
• Transvaginal ultrasound criteria, such as a homogenous intrauterine dimension of less than 11 cm^2, can be used to diagnose an "empty uterus" 5

Diagnostic Accuracy

• The ultrasound finding of hyperechoic material has a sensitivity of 78%, specificity of 100%, and positive and negative predictive values of 100% and 75%, respectively, in predicting RPOC 2
• Vaginal bleeding as a predictor of RPOC has a sensitivity of 93%, specificity of 50%, and positive and negative predictive values of 74% and 82%, respectively 2
• The combination of hyperechoic material and/or vaginal bleeding increases the sensitivity to 98% and negative predictive value to 95% 2

Clinical Implications

• Bedside ultrasound can be a rapid and accurate modality to evaluate patients with postpartum complaints, including suspected RPOC 6
• Earlier diagnosis of RPOC can lead to more focused patient evaluations and management 6