From the Guidelines
The most appropriate next step for this 30-year-old woman is to perform a follow-up transvaginal ultrasound in 7-10 days to confirm the diagnosis of a missed or incomplete abortion, as the current ultrasound shows a gestational sac without an embryo or heartbeat, which is concerning for early pregnancy loss 1. Given her presentation at 11 weeks with lower abdominal discomfort, vaginal spotting, and an ultrasound showing a gestational sac without an embryo or heartbeat, this likely represents an anembryonic pregnancy (previously called a blighted ovum) or early pregnancy loss.
- The criteria for diagnosing early pregnancy loss include a mean sac diameter (MSD) of 16-24 mm with no embryo, or the absence of an embryo with cardiac activity 7-13 days after visualization of the gestational sac and no yolk sac 1.
- While waiting for the follow-up ultrasound, serial quantitative beta-hCG measurements should be obtained 48 hours apart to assess if levels are appropriately rising (which they likely won't be in this case).
- After confirming the diagnosis, management options include:
- Expectant management
- Medical management with misoprostol (800 mcg vaginally or 600 mcg sublingually, potentially repeated after 24 hours if needed)
- Surgical management via suction dilation and curettage
- The patient should be counseled about all three options, with the choice depending on her preferences, clinical stability, and medical history.
- She should be advised to seek immediate medical attention if she experiences heavy bleeding (soaking more than two pads per hour for two consecutive hours), severe pain unrelieved by analgesics, fever, or signs of infection, as these could be indicative of complications such as infection or hemorrhage 1. This approach allows for definitive diagnosis before intervention while preparing the patient for the likely management of early pregnancy loss.
From the Research
Diagnosis and Next Steps
The patient's symptoms of lower abdominal discomfort and vaginal spotting, combined with the ultrasonography findings of a gestational sac with no evidence of an embryo or detectable heartbeat, suggest a diagnosis of missed abortion or anembryonic pregnancy.
Management Options
- Medical management with misoprostol is a highly effective and safe method for treating non-viable first trimester pregnancies, as shown in studies 2, 3, 4.
- A single dose of 800 microg vaginal misoprostol or 600 microg sublingually may be offered as an alternative to surgical treatment 3.
- The efficacy of medical treatment is high, with studies showing completion rates of 89-92.9% without the need for surgical intervention 2, 4.
- Mifepristone and misoprostol regimens are also safe and effective for outpatient treatment of early pregnancy loss, with gestational age determined using ultrasonography or menstrual history 5.
Considerations for Patient Care
- The patient should be advised to contact a provider in case of heavy bleeding or signs of infection 3.
- Follow-up is recommended after 1 to 2 weeks to confirm complete passage of the pregnancy tissue 3, 5.
- Ongoing pregnancy, infection, hemorrhage, undiagnosed ectopic pregnancy, and the need for unplanned uterine aspiration are rare complications that should be monitored 5.
Uterine Curettage
- Uterine curettage may be considered in cases where medical treatment fails or is not suitable, as it provides a definitive diagnosis and limits exposure to chemotherapeutic agents 6.