Chapter 2. First Trimester II Early Pregnancy Loss

Women’s Point of Care Ultrasound

Welcome to the chapter on Early Pregnancy Loss, or EPL. Detecting embryonic or fetal demise is a disturbing experience, for both mother and provider. It is a situation that requires compassion and appropriate communication with the mother and family. Because of the seriousness of the finding, it needs to be validated with other testing or at least confirmed with another provider. Failing to detect this can lead to maternal complications such as hemorrhage or infection. However, pregnancies that demonstrate signs of impending failure in the first trimester can result in a normal pregnancy. It is the role of the POCUS provider to be thorough in the assessment.

Objectives:

By the completion of this chapter the participant will be able to:

Define Early Pregnancy Loss, and describe other terms used for this condition

List both suspicious and certain findings for EPL.

Recognize sonographic sign of subchorionic hemorrhage

Recognize sonographic sign of anembryonic pregnancy

Describe use of M-mode and/or color flow to confirm embryonic demise

EARLY PREGNANCY LOSS: DEFINITION

Early pregnancy loss (EPL) is defined as a nonviable, intrauterine pregnancy within the first trimester (up to 12wks 6 days from LMP). Women prefer the terms “early pregnancy loss” or “miscarriage” over “early pregnancy failure” “or “spontaneous abortion”¹

Although ultrasound is indispensable for managing early pregnancy failure, if performed too early without adherence to guidelines, it can lead to inconclusive results or incorrect diagnosis.²

In a normally developing viable pregnancy, an embryo with cardiac activity must be demonstrated > 11 days after a gestational sac (GS) with a yolk sac (YS), or >14 days in which a GS without a YS was identified.^2,3

Risk Factors

Figure 1. Risk factors for EPL.

EPL risk factors include:

--Increasing age

Age 25-29 – incidence is 10%

Age >45 – incidence is 57%, likely due to the increase in chromosomal abnormalities

Prior pregnancy loss is also associated with a higher risk of loss in the current pregnancy

OR (adjusted odds ratio) of miscarriage after.⁴

—1 prior loss is 1.54

—2 prior losses is 2.21

—3 prior losses is 3.97

Common Causes

Common causes of EPL include:

--Chromosomal abnormalities

(These abnormalities are present in 70% of pregnancy losses before 20 wks.)

--Maternal anatomic anomalies can also cause a problem with implantation. Some of the more common maternal causes are:

--Uterine fibroids (more likely to cause complications if they are large, or if they impinge on the endometrial cavity)

--Polyps

--Adhesions

--Uterine septa

--Other uterine malformation

--Trauma, such as a motor vehicle accident or direct abdominal trauma. There are mixed data on the significance of intimate partner violence contributing to an EPL.

Clnical Signs

Figure 2. Clinical signs of EPL.

The two most common clinical signs of EPL are vaginal bleeding and cramping. Although bleeding or spotting is very common in early pregnancy (up to 20-30% of all pregnancies), about 12% of these will be in the process of losing a pregnancy. EPL is more likely if the bleeding is heavy.⁵

Many providers attempt to reassure women with any spotting or bleeding during the first trimester that she is experiencing “implantation” or “nidation” bleeding. However, this type of bleeding occurs during the first 2 weeks of gestation.6

Women commonly say that they suspected a problem when they suddenly noticed an absence of pregnancy symptoms they had previously been having.

Some women are totally asymptomatic and are unaware there is a problem. Women who have limited access to health care (such as remote areas) may have already passed the fetal tissue prior to being seen by a provider. The longer a woman waits with incomplete expulsion of products of conception, the greater the risk of hemorrhage and uterine infection.

Categories of EPL

The categories of EPL are described as

--Threatened (with early signs)

--Inevitable (failure of the GS to grow, or embryonic demise)

--Incomplete (retained tissue within the uterus, either fetal or placental)

Figure 3. Categories of EPL

--Complete: complete passage of pregnancy tissue (with or without intervention)

The categories may also be subdivided into:

--Asymptomatic: without bleeding, cramping, or passage of tissue

--Symptomatic. with bleeding and often cramping

It has been reported that neither bleeding or cramping alone are independent risk factors for EPL; however, the combination of the two makes the suspicion much greater.

There has been recent discussion about the validity of using so many different terms describing EPL. However, the above terms are still commonly used.

In looking for potential problems with the pregnancy, the structures to be assessed are as follows (in order of when these structures can first be seen with ultraosund).

Gestational sac
Yolk sac
Fetal (embryonic) pole
Embryonic cardiac activity
Amnion

Findings suspicious for EPL⁷

Findings that raise suspicion for EPL are described below(Figure 4)
Figure 4. Findings suspicious for EPL.

Diagnosis of EPL – Certain Criteria ^7,8

Once an IUP (intrauterine pregnancy) is identified on ultrasound, EPL is diagnosed if any subsequent ultrasound shows no IUP, or if there is no longer cardiac activity that was previously seen.

Other certain diagnostic criteria by ultrasound are listed in Figure 5.

Figure 5. Diagnosis of EPL - certain criteria.

Once an ultrasound between 6-12 weeks establishes a pregnancy with a normal heart rate, the risk of EPL decreases to about 1.6%.⁵

The rate of EPL varies when comparing bleeding with gestational age:

Gest Age	Heartbeat with bleeding	Heartbeat without bleeding
<6 wks	33%	16%
7-9 wks	10%	5%
10-11 wks	4%	1-2%

Table 1. Comparison of rates of EPL at various gestational ages in first trimester and whether there is presence of bleeding.

Process of diagnosing EPL

The diagnosis of EPL is made by a number of findings, including:

History:

--Vaginal bleeding and pelvic pain

-- LMP and certainty of LMP

Physical exam:

--Visible bleeding from the cervical os, and possible appearance of an open or softened os.

--Absence of fetal heartbeat using doppler if gestation is greater than 11-12 weeks (depending on body habitus)

Lab evaluation:

There are no set diagnostic ranges of BhCG levels that are diagnostic for EPL, but some indicators are:

1. Drop of >25% in BhCG levels 48 hours from the prior level

2. Low or decreasing progesterone levels.

The rationale is that a low progesterone level is an indication that the pregnancy does not have adequate progesterone support. A low progesterone can suggest EPL, but it is not diagnostic by itself. Some practitioners provide progesterone supplementation to women with low progesterone in early pregnancy to try to avoid a pregnancy loss. But evidence indicates that when the progesterone is low, the pregnancy is already failing. Despite lack of evidence for supplementing of progesterone in early first trimester, many practitioners (including ob/gyn physicians and fertility specialists) still prescribe it because it is thought to potentially help a woman at risk for miscarriage, with little or no ill effects for the pregnancy.

Differential Diagnosis

When a woman knows or suspects she is pregnant, and comes for care due to bleeding, cramping, or pelvic pain in the first trimester, these are the differential diagnoses to consider (Figure6):

Figure 6. Differential diagnoses for EPL

--Normal pregnancy – Some normal pregnancies have bleeding/spotting without sequelae.

-- Subchorionic hematoma (sometimes termed ‘hemorrhage’, or “bleed”). An SCH (subchorionic hemorrhage) is a collection of fluid or blood beneath the chorionic plate, sometimes with elevation of the membrane from the chorion. It appears as an irregularly shaped, mixed echogenic region without color flow.

--Ectopic pregnancy – Until imaging demonstrates a gestational sac, yolk sac, and embryo inside the uterine cavity, there is a possibility that a pregnancy could be an ectopic or PUL (pregnancy of undetermined location). Ectopic pregnancy is described in more detail in chapter 4 of this course.

--Hydatidiform mole (trophoblastic disease)– This is an complication causing abnormal gestational tissue to grow inside the uterus, usually without a normal embryo present.

Sonographic signs of abnormal pregnancy

Ultrasound is the imaging modality of choice to determine the presence and/or viability of an early gestation.

The signs to look for when suspecting an EPL or even early pregnancy complication include:

--GS is too large or empty

--GS too small for contents: ^2:Bromley et al demonstrated risk of SAB was 94% for a small GS despite normal cardiac activity

--Poor decidual reaction

-- Low implantation of GS

--Irregular size/shape of YS; YS greater in size than 7 mm is a concerning threshold

--Duplication or absence of YS

-- Subchorionic bleed

Figure 7. Sonographic signs of abnormal pregnancy.

Sonographic findings in early pregnancy loss: Threatened ab

A “threatened ab” is defined as the presence of clinical signs of a potential miscarriage, with a pregnancy that is still viable.

Figure 8. Two most common indications for early pregnancy POCUS.

It is common to hear women being told that when she has any spotting or bleeding, it is due to “implantation” bleeding. However, that statement can be misleading if the spotting occurs after the 3rd week of pregnancy. Nidation or implantation bleeding occurs in the first 2 weeks of gestation, and not after that.

Figure 8. Two most common indications for early pregnancy POCUS.

When vaginal bleeding is present it is important to:

1. Look for hypoechoic region outside the GS, between the chorion or placenta and the myometrium in late first trimester, suggestive of subchorionic bleed. It can be associated with spontaneous abortion (SAB), but in many cases it is insignificant if small.

2. Calculate GS volume to compare to the volume of the subchorionic hemorrhage (SCH). If the area of bleed is less than 25% of GS volume, the pregnancy has a good chance of progressing

3. Look for debris or contents in the cervical os, indicating an imminent spontaneous abortion (SAB).

4. Refer for full diagnostic scan even if reassured

First Trimester Problems – Subchorionic hemorrhage

One of the most common findings when performing a POCUS exam is the presence of subchorionic bleeding or hemorrhage. It may be small and resolve without incident. However, size and location determine the impact on the developing pregnancy.

An SCH (subchorionic hemorrhage) is a collection of fluid or blood beneath the chorionic plate, sometimes with elevation of the membrane from the chorion. The red arrows point to the irregularly shaped, hypoechoic areas that represent subchorionic hematoma. Finding a subchorionic bleed is not always a predictor of pregnancy loss. The risk of SAB increases with size of the SCH.¹⁰ This can occur in a viable pregnancy, often with complete resolution as the pregnancy advances.

Image 1. Subchorionic hemorrhage at 9w6d.

The red arrows in Image 1 (above) point to the irregularly shaped, hypoechoic areas representing subchorionic hematoma.

A subchorionic hemorrhage can often be seen in a normally progressing pregnancy. It may be important to describe to the woman the presence of an SCH, and to reassure her that it is likely to resolve. She may or may not have had any spotting or bleeding associated with it. Bleeding is more likely to be experienced if the SCH is low in the uterus or near the cervix. The other thing to discuss with the woman is that the word “hemorrhage” does not indicate a large amount of blood, as the term is commonly used, but rather a very small area of blood.

The area indicated in Image 2 (below) is a smaller section of a hematoma; however, a concerning feature is the irregularity to the shape of the sac itself. The shape of the GS is also irregular, suggesting early collapse of the sac. Another concern is the lack of a YS or fetal pole, both of which should be easily noted in a sac that size.

Image 2. Subchorionic hemorrhage adjacent empty GS.

Image 3. Large SCH at internal cervical os.

In the images below (image 4) there are two notable SCH areas. If the woman has had no bleeding, she may have a follow up POCUS exam in a month to determine if the SCH areas have resolved.

Image 4. SCH at 6w3d

.

Below (image 5) is an image of what appears to be a walled-off area of blood in the left upper area of the uterus. This has a different configuration than the typical SCH since it has a smooth echogenic border.

Image 5. SCH versus walled-off hematoma in left upper uterus with early gestation.

ANEMBRYONIC PREGNANCY

Other signs of pregnancy loss are an empty gestational sac, when by size or dates there should easily be a viable embryo. This is termed “anembryonic gestation” meaning without a visible embryo. Some have termed this condition as a “chemical pregnancy” or “blighted ovum”, indicating that there was never an embryo. However, it is more likely an embryo lost viability early and was absorbed before it could be detected on ultrasound.

The earliest sonographic detection of an anembryonic gestation varies by the type of ultrasound transducer used. ⁹summarizes that in this table:

GS size using TRANSABDOMINAL	GS size using TRANSVAGINAL
>20 mm MSD with NO YS	>13 mm MSD with NO YS
>25 mm MSD with NO embryo	>18 mm MSD with NO embryo

Table 2. Comparison of size of GS when is visible by ultrasound; transabdominally versus transvaginally.⁹

There are two ways that an anembryonic gestation can present. The first is with a YS and amnion, but without an embryo or fetus. The second is with a gestational sac only, without other pregnancy structures.

Large YS, no fetal pole

Sometimes an EPL is signaled by an abnormal size of the YS. An abnormal YS would be one that is small (2mm or less) or large (greater than 5-6mm).¹⁰ Below is an example of a large YS (image 6). There is no visible embryo either, so this image is non-reassuring.

Image 6. Gestational sac with large YS and no fetal pole.

Below are examples of empty gestational sacs (Images 7, 8). The one on the right has the additional concern of an irregular shape. We do not see any obvious sign of subchorionic hemorrhage, except for some tiny spaces in the right Image toward the top of the gestational cavity.

When determining if a gestational sac is empty, it is IMPERATIVE that you scan through the entire sac/uterus in both transverse and sagittal views so that a small embryo or fetus is not missed.

Images 7,8. Empty GS on left, irregularly shaped GS with SCH on right.

Empty gest sacs 2

Images 9 & 10 are are additional images of empty gestational sacs. The image on the left is a transabdominal view, showing that the sac measured 3.55 cm in one diameter (well exceeding the 2.5 CM limit for when you should be able to see an embryo easily). The same is true for the image on the right. Color flow was even applied to this to try to detect a possible tiny fetal heart activity, but no color flow was seen in the embryo.

Images 9,10. Two images of empty GS. The image on the right demonstrates the absence of color flow into the GS.

Image 11. Irregular GS. Yellow arrow points to the amnion and there is a small ring at the bottom of the GS that appears to be a YS

Image 12 (below) shows a fairly large gestational sac that has collapsed. It is indeterminate as to whether this represented a single sac, double sac, or even a triple sac.

Image 12. Collapsing GS

7 wk gestation by LMP

The gestation in Image 13 is not normal. First of all, the gestational sac is very irregular, and it certainly does not meet the size criteria (by observation) of a 7 week gestation. We should see a well-developed embryo at this stage if the pregnancy is truly 7 weeks by LMP. Inside the sac there is irregular tissue – and a fetal pole is not easily identified. Using color flow, there is a small amount of blood flow evident at the top of the gestational sac. It is possible that this is post-miscarriage debris or an incomplete abortion/miscarriage.

Image 13. Irregular gestation with indeterminate contents at 7 weeks by LMP

Sonographic findings In EPL – Missed ab

Irregular GS, no fetal cardiac

Below is an image of a pregnancy dating 9 weeks by LMP (Image 14). This image demonstrates several things. The view is in a transverse plane (because it says TRV UT in the upper left of the image (as annotated by the sonographer). There is a definite YS on a vitelline stalk, but the embryo has an irregular shape. Also note that the inside contour of the gestational sac is not smooth, but irregular, and a small area of subchorionic hemorrhage is indicated by the blue arrow. All of these are indicative of a pregnancy loss.

Image 14. IUP at 9 weeks by LMP with irregular sac and no color flow to embryo.

Small gest sacs

The other indicator of a failing pregnancy is the presence of abnormally small sacs. However, not all small sacs mean that there will be a pregnancy loss. It is important to measure them over time, and continue to observe, especially if there is a good fetal heart rate. In mage 15 a fetal pole and a YS are seen, although the YS in the right image appears a bit irregular in shape.

Image 15. IUP with embryo and irregularly shaped YS, small GS size.

Small GS, no cardiac

Image 16 is of a fetus measuring 7w 2d demonstrates a true embryonic demise. The embryo at 7+ weeks should have a clearly identified fetal heartbeat. However, even with color flow, no activity is seen. So this is considered a “missed” ab or “missed miscarriage”. The correct term for this is “embryonic demise”. There are no symptoms of miscarriage yet, but the embryo is no longer viable, and miscarriage will eventually happen.

Image 16. Fetal pole measuring 7w 2d and absence of color flow. Small GS.

Image 17 has some concerns relate to the sac size relative to the fetus. This would warrant close observation and repeat POCUS.

Image 17. Early IUP at 6w0d. YS is seen on the right. Indeterminate viability since fetal heartbeat is not seen.

No cardiac at 7.5 wks

Image 18 shows a definite embryonic demise. At this gestation, with an accurate CRL measurement, the fetal heartbeat should be seen but is not, even with color application.

Image 18. IUP at 7.5 wks with absence of color flow.

No cardiac by color flow at 8 wks

Image 19 is of an embryo in a woman who had a known and certain LMP, with a history of regular menses. The embryo is clearly identified, but there is no heartbeat. Given the true size of the embryo (6 wk. 3 d), a fetal heartbeat might be seen, especially using color flow. However, since this is very close to the 6-week gestation, if there is any doubt about viability, one should wait another week and rescan, to be certain and to “give the fetus a chance”. Although the GS has a bit of irregular shape, there is no sign of subchorionic hemorrhage, which is reassuring.

Image 19. IUP at 8w0d by certain LMP. Fetal pole measures 6w3d and has no internal color flow.

Early demise

Image 20 shows a collapsing GS at the internal cervical os. When scanning through the entire gestational sac in different planes, this is the only tissue seen.

Image 20. Collapsing GS and YS noted at internal cervical os.

Low implantation at 5.5 wks

These two images of the same pregnancy below (Image 21) demonstrate a low implantation of the embryo. The one on the right is viewed with color flow, which is not considered appropriate unless the viability of the pregnancy is in question (such as bleeding, or no perceptible heartrate).

Image 21. Low implantation of 5w5d pregnancy. Fetal pole is seen to have internal color flow.

As seen by the CGA listed (CGA means calculated gestational age provided by the computer), this embryo measures 5w 5d, which may be too early to see a fetal heartrate.

Low implantation?

Carefully look at this Image 22 to see if the YS is low-lying. Keep in mind that there is no annotation describing whether this is a transverse or long view of the uterus.

Image 22. Early gestation at 6w0d and orientation is not annotated. Unclear of this is a low-lying GS.

In this case there are 2 things to know:

1. The cervix is not clearly seen toward the right of the image, where it would be if the view was sagittal.

2. The YS is not in the same place as the fetal pole – and it is the fetal pole’s position that is most important.

Image 22. Now annotated. Orientation is transverse so the YS is in the left uterine cavity.

This is NOT a low implantation because the orientation of this scan was not described. Therefore, there is no way of telling whether this was a sagittal view or a transverse view.

If the image was correctly annotated, it would have been labeled as a transverse uterine view. The fetal pole would NOT be near the cervix, but instead in the left part of the uterine cavity. The YS is at the maternal left in the uterus, and the fetal pole is toward the back of the uterus – perfectly normal. This demonstrates the importance of correct orientation to the uterus, and accurate annotating.

Small post fibroid, plac overlying

One risk factor for EPL, mentioned in a previous slide, was the presence of fibroids. Not all fibroids represent a problem for pregnancy. Their impact on pregnancy has more to do with location and size, and the most problematic seem to be those that are:

--submucosal

--intramural and large

--in the cornual region

--in the lower uterine segment and impinging on the cervix (with a potential for disrupting cervical integrity or causing obstruction during labor)

The area seen in this image is considered to be a fibroid since there are clear hypoechoic margins that delineate its borders.

First Trim with fibroid

In Image 23 there is a small submucosal fibroid impinging on the chorion, with a small area of hematoma adjacent to it and the chorion. This fibroid location is of more concern since it is within the decidual area and could potentially interfere with subsequent placental attachment and function

Image 23. IUP with posterior subserosal or myometrial fibroid.

As mentioned earlier, the location of the fibroid affects the risk of pregnancy complications such as bleeding. The image below shows a submucosal fibroid, which typically carries the greatest risk to a pregnancy since it shares the blood supply and occupies space inside the uterine cavity.

Image 24. IUP with submucosal fibroid and small SHC. All are within the chorionic region.

Fundal fibroid with IUP

In Image 25 there is a first trimester gestation, and a small well-defined fibroid that is partly pedunculated to the right of the uterus (on the left side of the image). Since this fibroid is outside the uterus, and it is relatively small (3.4 X 2.9 X 2.5 cm) it should not present problems for the pregnancy.

Image 25. IUP with subserosal fundal fibroid.

Contraction vs fibroid?

Below is an image of a 12w 5d fetus that has some anterior impingement. At first sight, it could appear to be a possible fibroid. But there is not a clearly defined border. To determine whether this is a contraction or fibroid, waiting about 10-15 minutes to rescan in this same plane, would show the contraction to have resolved.

Contractions are commonly seen while scanning, especially during first trimester when they appear “large” in comparison to the uterine or fetal size. However, they are benign and do not indicate impending labor, nor do they predict preterm labor. The woman needs an explanation of this if a contraction is noted or mentioned so she does not become alarmed about potential risk of preterm labor.

Contraction vs fibroid? 2

Image 26 is another image of an early gestation with a bulge that likely represents a uterine contraction.

Image 26. IUP at 12w5d and anterior contraction.

Reporting and documenting the early pregnancy loss

A report should be worded, “findings consistent with miscarriage or early fetal demise”, and should include an image demonstnnrating the findings.

Some facilities require a second sonographer to confirm the diagnosis of demise.

Retained products of conception after SAB

There can sometimes be remaining tissue after a miscarriage or elective abortion, causing persistent bleeding. If the bleeding has persisted over 7-10 days, an pelvic ultrasound is beneficial to look for retained products of conception (RPOC) in the uterine cavity. These contents can appear to have mixed echogenicity and will distend the endometrium irregularly. Color doppler is helpful in determining if this tissue is still receiving blood supply from the endometrium, demonstrating that the POCs have not been completely expelled. If this is seen, it is important to refer the woman for medical or surgical management. When documenting this finding, the report should include the following.¹¹

--absence of a gestational sac

--description of the endometrial cavity with measurements

--recording (image) of the presence or absence of color flow into the tissue

If a prostaglandin medication such as misoprostel is used, the woman should return for a follow up POCUS to be sure that the POCs are completely expelled.

Image 27. Products of conception demonstrating vascularity to the region using color flow.

Images 27 and 28 show abnormal endometrial properties for post-SAB or post treatment for retained products of conception. Image 27 shows remaining tissue with a blood supply that requres treatment. Image 28 shows a thickened endometrium which can be abnormal if the woman is still bleeding after a week post-treatment. Specific management of post-ab retained products of conception is not addressed in this course. The purpose of POCUS is to identify its presence so treatment and/or referral can be provided.

Image 28. Sagittal view of uterus showing residual tissue after misoprostel treatment for missed ab.

FETAL DEMISE

As defined earlier, the term fetus is designated for a gestation that is past 8 weeks, or when distinct fetal features are noted. Although early first trimester miscarriages are more common, late first trimester loss is also a potential. When the woman has no symptoms, and the demise is discovered at a routine prenatal visit, it is a distressing event. Care must be made to be certain that a demise is confirmed. If there is no detectable fetal heartbeat using M-Mode then color flow is indicated to attempt to find circulation in the fetus. The absence of color flow is a certain indication of fetal demise.

Image 29. Fetus at 8w 5d and no color flow. Fetus appears to be collapsing.

Image 30. Fetal demise at 10w3d by LMP. Note the presence of the amnion.

Below (Images 31,32) include a fetus first identified as having no cardiac motion with use of M-Mode and then noted to have no internal color flow.

Images 31,32. Fetus at 8 weeks with no color flow.

The images below show the progression of a fetus seen at 6 wks with recorded fetal heartbeat. Then at 10w5d there was no longer any cardiac motion. There was also a membrane noted to be adjacent to the fetus, possibly indicating a collapsing aminon.

Images 33, 34, 35. Top image is of viable embryo at 6 wks. Subsequent ultrasound at 10w 5d demonstrates no heart rate and there is a membrane surrounding the fetus that could represent a collapsing amnion.

SUMMARY

Definition of EPL: Nonviable, intrauterine pregnancy within the first trimester (up to 12+6 wks. from LMP)
EPL is one of the most common complications of pregnancy, affecting from 10% to over 50% of pregnancies, depending on maternal age
Chromosomal abnormalities are found 70% of pregnancy losses before 20 wks
Other causes of EPL include uterine malformations and trauma
Clinical symptoms of EPL are vaginal bleeding and/or pelvic cramping. However, each of can be due to other complications
Criteria for diagnosing a failed pregnancy:

Gest sac >25 mm with no yolk sac or embryo

Embryo with CRL >7 without cardiac activity

Prior ultrasound showed GS without YS, now there is no embryo with a heartbeat in >2wksd

No cardiac activity >11 days after demonstrating a gest sac and a yolk sac

Prior ultrasound showed GS WITH YS, now there is no embryo with a heartbeat in >11 days

It is important to provide adequate counseling and support for women and families experiencing EPL .

Each pregnancy has significance and may involve mourning and/or guilt.

The POCUS provider should consult with an advanced provider to determine best management if it is not within his/her scope of practice.

May include options of expectant , medical, or surgical management

YOU MAY NOW TAKE THE QUIZ AND MOVE TO THE NEXT CHAPTER. YOU WILL NOT BE ABLE TO OPEN THE NEXT CHAPTER UNTIL YOU COMPLETE AND PASS THE QUIZ WITH 100%. YOU WILL HAVE AS MANY TRIES AS YOU NEED TO GET ALL THE ANSWERS CORRECT!

Women's Point-of-Care Ultrasound: First Trimester

First Trimester II Early Pregnancy Loss (EPL)