Every woman with an early pregnancy, vaginal bleeding, and pain should be evaluated. he primary goal is prompt diagnosis of ectopic pregnancy, and serial quantitative serum S-hCG levels and transvaginal sonography are integral tools. Because these are not 100-percent accurate to confirm early embryo death or location, repeat evaluations are often necessary. With a robust uterine pregnancy, serum S-hCG levels should rise at least 53 to 66 percent every 48 hours (Barnhart, 2004c; Kadar, 1982). Although a less-used marker, serum progesterone concentrations <5 ng/mL suggest a dying pregnancy. Values >20 ng/mL support the diagnosis of a healthy one (Daily, 1994).
Transvaginal sonography is used to locate the pregnancy and determine viability. If this cannot be done, then a PUL is diagnosed, and serial surveillance is implemented for clinically stable women. The gestational sac-an anechoic fluid collection that represents the exocoelomic cavity-may be seen by 4.5 weeks (Fig. 9-3, p. 159). At this same time, S-hCG levels generally measure 1500 to 2000 mIU/mL (Barnhart, 1994; Timor-Tritsch, 1988). Connolly and colleagues (2013) observed that this value could be as low as 390 mIU/mL. However, they also noted that a threshold as high as 3500 mIU/mL may be needed to identiY the gestational sac in some cases that ultimately yield a viable singleton IUP.
Another caveat is that a gestational sac may appear similar to other intrauterine fluid accumulations-the so-called pseudogestational sac (Fig. 19-4, p. 375). his pseudosac may be blood derived from a bleeding ectopic pregnancy and is easier to exclude once a yolk sac is seen. Typically, the yolk sac is visible by 5.5 weeks and with a mean gestational-sac diameter of 10 mm. Thus, the diagnosis of an IUP should be made cautiously if the yolk sac is not yet seen (American College of Obstetricians and Gynecologists, 20 16h).
For management of threatened abortion, observation is the norm. Acetaminophen-based analgesia will help relieve discomfort from cramping. Bed rest is often recommended but does not improve outcomes. The hematocrit and blood type is determined. If anemia or hypovolemia is signiicant, then pregnancy evacuation is generally indicated. In cases in which there is a live fetus, some instead may choose transfusion and further observation.
During abortion, bleeding follows partial or complete placental separation and dilation of the cervical os. Before 10 weeks' gestation, the fetus and the placenta are frequently expelled together, but later, they deliver separately. hus, tissue may remain entirely within the uterus or partially extrude through the cervix. Products lying loosely within the cervical canal can be easily extracted with ring forceps. In contrast, with incom plete expulsion, three management options include curettage, expectant management, or misoprostol (Cytotec), which is prostaglandin EI (PGEI) (Kim, 2017). he last two are deferred in clinically unstable women or those with uterine infection.