Peter Michael Doubilet MD, PhD, Presenter: Nothing to Disclose

1) Know the sonographic criteria for definite miscarriage and probable miscarriage in the early first trimester. 2) Understand that any saclike intrauterine structure (rounded edges, no yolk sac or embryo) in a woman with a positive pregnancy test is highly likely to be a gestational sac. 3) Understand that nonvisualization of an intrauterine gestational sac in a woman with hCG above the "discriminatory" level (2000 mIU/ml) does not exclude the possibility of a viable pregnancy.

I. Sonographic Criteria for Diagnosing Pregnancy Failure (Miscarriage) in an Intrauterine Pregnancy of Uncertain Viability [Note: an intrauterine fluid collection with rounded edges in a woman with positive hCG is almost certainly a gestational sac; it is definitely a gestational sac if it contains a yolk sac or embryo.] 1. Criteria for definite miscarriage (i) CRL <=7 mm and no heartbeat; (ii) MSD <=25 mm and no embryo; (iii) Absence of embryo with heartbeat >=2 weeks after a scan that showed a gestational sac without yolk sac; (iv) Absence of embryo with heartbeat >=11 days after a scan that showed a gestational sac with yolk sac 2. Criteria suspicious for miscarriage (i) CRL <7 mm and no heartbeat; (ii) MSD 16-24 mm and no embryo; (iii) Absence of embryo with heartbeat 7-13 days after a scan that showed a gestational sac without yolk sac; (iv) Absence of embryo with heartbeat 7-10 days after a scan that showed a gestational sac with yolk sac; (v) Absence of embryo >=6 weeks after LMP; (vi) Empty amnion (amnion seen adjacent to yolk sac, with no visible embryo); (vii) Enlarged yolk sac (>7 mm); (viii) Small gestational sac size in relation to the embryo   II. Guidelines Related to the Possibility of a Viable Intrauterine Pregnancy in a Pregnancy of Unknown Location (positive pregnancy test and no intrauterine or ectopic pregnancy seen on ultrasound) 1. A single hCG, regardless of its level, does not reliably distinguish between ectopic and intrauterine pregnancy (viable or nonviable) 2. If a single hCG is <3000 mIU/ml, presumptive treatment for ectopic pregnancy using methotrexate or other medical/surgical means should not be undertaken, in order to avoid the risk of interrupting a viable IUP 3. If a single hCG is >=3000 mIU/ml, a viable intrauterine pregnancy is possible but unlikely. However, the most likely diagnosis is nonviable IUP, so it is generally appropriate to get at least one followup hCG before treating for ectopic pregnancy.

<a href="http://media.rsna.org/media/abstract/2013/13010306/RC210A DoubiletSECURED.pdf" target="_blank">http://media.rsna.org/media/abstract/2013/13010306/RC210A DoubiletSECURED.pdf</a>

Doubilet, P, Diagnosis of Nonviable Pregnancy.  Radiological Society of North America 2013 Scientific Assembly and Annual Meeting, December 1 - December 6, 2013 ,Chicago IL. http://archive.rsna.org/2013/13010306.html