Bleeding Without Visible IUP
Anne Kennedy, MD
DIFFERENTIAL DIAGNOSIS
Common
Complete Abortion
Very Early Normal Pregnancy
Retained Products of Conception
Tubal Ectopic
Less Common
Complete Hydatidiform Mole
Rare but Important
Abdominal Ectopic
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
It is essential to confirm patient is actually pregnant
Ruptured hemorrhagic cyst can present in similar manner to ectopic pregnancy
Most cyst ruptures are managed conservatively
Bleeding ectopic pregnancy requires surgery
Check urine pregnancy test ± quantitative beta hCG in all cases
Tubal ectopic must be ruled out in every case
If patient clinically unstable laparoscopy may be required to establish diagnosis
Blood in pelvis obscures serosal margins
Patients are often in pain and cannot tolerate transducer pressure
Positive pregnancy test & blood in pelvis & unstable patient requires laparoscopy
If stable then “wait and see” approach is reasonable
Follow serial beta hCG at 48 hr intervals
Repeat ultrasound when beta hCG reaches threshold levels or if symptomatic change
Avoid presumptive diagnosis of ectopic
Must know normal early pregnancy development and milestones to avoid this mistake
Do not give methotrexate to a patient with a possible early intrauterine pregnancy (IUP)
Therapeutic abortion required if methotrexate spontaneous abortion does not occur
Helpful Clues for Common Diagnoses
Complete Abortion
Uterus empty with os closed
Beta hCG will decrease on follow-up
Very Early Normal Pregnancy
Bleeding in pregnancy before visualization of gestational sac (presumed to be implantation bleeding)
Commercial pregnancy tests now very sensitive: Positive on day 1 of missed menses
At 4-4.5 weeks menstrual age may not see any sonographic evidence of pregnancy
Transvaginal (TV) sonography mandatory for best resolution
Beware tiny cystic structures in endometrium, may be dilated endometrial glands
Follow all apparent IDSS to ensure normal developmental milestones
If quantitative beta hCG low and patient stable repeat at 48 hr intervals
If doubling normally likely early IUP
Repeat scan once beta hCG > 2,000 IU
Retained Products of Conception
Material in endometrial cavity
Echogenic more suspicious than hypoechoic
Look for feeding vessels on color Doppler
Tubal Ectopic
Beta hCG at level where IUP should be seen (> 2,000 IU)
No intrauterine gestation sac
Look for adnexal mass
Tubal ring moves separately from ovary with transducer pressure
“Ring of fire” on color Doppler interrogation due to trophoblastic flow
Remember corpus luteum also has “ring of fire” but will be in or move with ovary
Look for hematosalpinx
Tubular adnexal structure with echogenic, non-perfused contents
Due to hemorrhage into lumen of tube
Occurs before tubal rupture leads to intraperitoneal bleeding
Beware pseudosac in uterus
Fluid collection central in uterine cavity
Normal gestation “burrows” into endometrium, therefore eccentric or intradecidual
No intradecidual sac sign (IDDS)
No double decidual sac sign (DDSS)
Flattened shape
No recognizable internal structures: May contain low echogenicity amorphous
Normal IUP has yolk sac ± embryo
Echogenic fluid in cul-de-sac correlates strongly with bleeding
Pus also creates echogenic fluid but pregnancy test negative, patient presents with fever/elevated white cell count
Helpful Clues for Less Common Diagnoses
Complete Hydatidiform Mole
Technically “product of conception” but abnormal so no embryo
Uterus distended by mass with hydropic chorionic villi creating a “bunch of grapes” or snowstorm appearance
Beta hCG may be very high
Look for theca lutein cysts in ovaries
Seen in 25% of cases
Often large for dates with hyperemesis ± hypertension
Helpful Clues for Rare Diagnoses
Abdominal Ectopic
Gestation implanted outside uterus within peritoneal cavity
Amniotic sac intact therefore embryo/fetus surrounded by fluid
May see multiple placental implantation sites
Uterus is empty and deep in maternal pelvis
ALWAYS make sure that the fetus is IN the uterus
Follow cervix to anterior and posterior myometrium
Other Essential Information
Time line, clinical history and prior lab/imaging information are important
When did urinary pregnancy test become positive?
Cervix open or closed?
Are there any prior scans?
If confirmed prior IUP with empty uterus now complete abortion is most likely diagnosis
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