The Use of Ultrasound Technology and Quantitative HCG Testing In the Diagnosis of First Trimester Miscarriage

Friday, May 21, 2010; second trimester with Freya.

Note:  The following is an essay that I wrote for a college course during the summer of 2009, while going through a miscarriage.  I had started bleeding in at 6 weeks.  The pregnancy lasted into week 14 before it finally ended.  Today, my baby, Freya, is 3 months old.  I found out I was pregnant with her near the time I would have birthed that miscarried baby.  Luna, now 3.5, was conceived 3 months after a miscarriage that started at 6 weeks and finally ended in week 12.  My first semester of college (Fall 2003) I had a miscarriage at 6 weeks.  The forum discussed in this essay helped me through those hard times, and I shared my joys with them when Luna and Freya were born.  When  I wrote this essay, I tallied posts that were on that forum at that point.  Since then, many other women have posted their joyful outcomes to the site, so my numbers are probably understated.  For some reason I felt moved to post this up today.  I did not put my typical lyrical snippets at the end of this post; instead you’ll find the “works cited” section that formal academic essays require.  I’m pretty sure I am legally required to tell you that I am not a medical professional. 

It is common practice in most Emergency Rooms (ERs) and Obstetrics and Gynecology (OBGYN) offices to use ultrasound technology and quantitative Human Chorionic Gonadotropine (HCG) blood testing to diagnose a pending miscarriage in the first trimester. Using personal testimonies of a large group of women who visited a forum for women who had been diagnosed with miscarriage (Kay) as well as a few articles on the subject of first trimester miscarriage diagnosis, the potential problems and advantages of the use and evaluation of these tests will be discussed, as well as safe alternative or additional methods for determining the outcome of a threatened miscarriage.

What are some commonly accepted facts about first trimester miscarriage? A woman is going to miscarry if her HCG level is over 10,000 and no baby is seen in the gestational sac during a routine ultrasound. A gestational sac measuring small for dates is evidence of a blighted ovum. After a certain stage of gestation or a certain sac size, a baby should be seen via ultrasound. Low HCGs, slow rising HCGs, and declining HCGs are all indicative of a pending miscarriage. After a certain stage of gestation, a healthy fetus will show a heartbeat and it will be of a certain rate and continue to be seen at that rate. Spotting or heavy bleeding in the first trimester is indicative of a pending or already occurred miscarriage. Yolk sacs should not be too large after a certain stage of gestation. Gestational sacs should consistently measure larger and larger with each repeated ultrasound and should maintain a certain shape.

A woman is going to miscarry if her HCG level is over 10,000 and no baby is seen in the gestational sac during a routine ultrasound. Fifty of the women who shared their stories on the forum noted that their levels were above 10,000 and the ultrasound technician was unable to find a baby via ultrasound. After waiting a few weeks and repeating the ultrasound, these women were able to see their babies via ultrasound. Many women discovered that their uterus was retroverted.

A gestational sac measuring small for dates is evidence of a blighted ovum. Twenty-three of the women who shared their stories on the forum were told that they were suffering from a blighted ovum or that their gestational sack had no baby inside and that they were measuring too small for their dates. After waiting a few weeks and repeating the ultrasound, these women were able to see their babies via ultrasound. In many of these cases, a retroverted uterus was once again to blame for the discrepancy in gestational size. Further measurements later in the pregnancy were able to show a healthy properly-measuring fetus.

After a certain stage of gestation or a certain sac size, a baby should be seen via ultrasound. Nine of the women who shared their stories on the forum were told that they were too far along, their HCGs too high, or their sacs too large to not see a fetus. Their uteruses were not retroverted. Repeated ultrasounds further in the pregnancy found viable fetuses. Some causes for the fetus not being seen earlier were a thickened uterine lining due to disorders such as endometriosis, scar tissue in the uterus due to prior surgeries or other disorders, tumors or cysts in the uterus, or simply malfunctioning ultrasound equipment.

Low HCGs, slow rising HCGs, and declining HCGs are all indicative of a pending miscarriage. Twenty-eight of the women who shared their stories on the forum were told that their HCG levels were too low, were slow-to-rise, or were declining in the first trimester. These women went on to carry healthy pregnancies. One known culprit in HCG level fluctuation is maternal dehydration (Medicine Online). Another cause is the natural fluctuation and leveling off of HCG levels towards the end of the first trimester, which in some women can actually occur closer to the beginning of the first trimester (Davis).

After a certain stage of gestation, a healthy fetus will show a heartbeat and it will be of a certain rate and continue to be seen at that rate. Eleven of the women interviewed were told that their baby either did not present a heartbeat, or the heartbeat was too slow, or the heartbeat had been seen on one ultrasound but not on a repeated ultrasound. Waiting a few weeks for follow-up testing revealed healthy fetuses with healthy heartbeats.

Spotting or heavy bleeding in the first trimester is indicative of a pending or already occurred miscarriage. Forty of the women who shared their stories on the forum were told that their spotting or heavy bleeding meant an inevitable or already occurred miscarriage. In some cases HCG testing and/or ultrasounds were used to aid in the diagnosis of miscarriage. After waiting a few weeks for repeated testing, these women were able to find a healthy fetus. In some cases, the women found their babies on accident after accepting the diagnosis of miscarriage. Other causes for first trimester bleeding that do not mean a completely ended pregnancy are subchorionic hematomas (Hematoma), miscarrying a twin or higher order multiple (American Pregnancy Association), placenta previa (Merk), natural sloughing off of uterine lining not being used in the pregnancy (DiLeo), and—in some extremely rare cases—continuing to ovulate and have periods during pregnancy.

Yolk sacs should not be too large after a certain stage of gestation. Three of the women who shared their stories on the forum were unnecessarily scared into thinking their pregnancy would end in miscarriage after an ultrasound determined a yolk sac that was too large for the stage of pregnancy. Research on the subject of yolk sac size turns up conflicting reports where some indicate large yolk sacs are linked to genetic deformities and other reports indicate large sacs have no relevance.

Gestational sacs should consistently measure larger and larger with each repeated ultrasound and should maintain a certain shape. Seven of the women who shared their stories on the forum were told that their gestational sacs were not growing, were growing too slowly, or were misshapen in some way. Repeated testing later in the pregnancy revealed healthy fetuses. As with the possible blighted ovums, retroverted uteruses, thickened uterine lining, uterine scar tissue, tumors or cysts in uterus, or malfunctioning ultrasound equipment were all possible culprits in disguising the size and shape of the gestational sacs.

In all of the above mentioned cases, doctors assumed the women were going to miscarry because the maternal symptoms and/or test results seemed to point to such an outcome. In all of the above mentioned cases, the women were given the option of D and C or D and E surgery, miscarriage-inducing medications, or the wait-and-see approach. Women who opted for one of the procedures but had a final ultrasound performed were surprised to find their babies after accepting their doctor’s diagnosis of miscarriage. Women who took the wait-and-see approach and insisted on a repeated ultrasound were surprised to find their babies after accepting their doctor’s diagnosis of miscarriage. Women who had the procedures done either found out the fetus had been viable after testing was done on the aborted tissue, or found out that the fetus survived the procedure. In some of the cases where the fetus survived the surgery or medication, maternal and fetal health were at risk throughout the pregnancy and in some cases the baby died later in pregnancy or after birth. Some women assumed they were going to miscarry and went back to unhealthy lifestyle choices (i.e. cigarettes, alcohol, self-medicating, poor diet, overtly strenuous exercise) only to discover they were pregnant still and had potentially been harming their unborn children.

When a woman presents to her physicians office or local ER with first trimester bleeding, ominous or irregular ultrasound results, or improperly fluctuating HCG levels, she should not be treated as a woman going through a miscarriage. IV fluids to rehydrate the mother should be administered as standard procedure for all pregnant women regardless of pregnancy stage. Progesterone levels should always be checked, and women with low levels should be offered the option of taking progesterone supplements. Although ultrasounds and HCG levels should still be standard procedure, women should be allowed to actively participate in their own diagnosis. They should be informed of all possible causes and outcomes, both positive and negative.

As the testimonies of so many other women have shown, the accepted facts about first trimester miscarriages are sometimes proven to be incorrect. Unless a pregnancy is threatening the mother (i.e. ectopic, infected, hemorrhaging) a surgical or chemical abortion should not be suggested or performed. The wait-and-see approach in an otherwise healthy mother seems to be the best way to ensure the full health of the mother—as convincing a woman she is to miscarry and then telling her she actually is not going to miscarry can cause harmful psychological effects—and the best way to ensure the full health of the baby—as mothers who are sure they have or will miscarry may not take care of themselves.

Terms used:

ultrasound technology—machines used to show the pregnancy by bouncing sound waves off, types include transvaginal where a wand is inserted into the vaginal canal to get a closer view of the uterus in early pregnancy and abdominal ultrasound where a wand is rubbed across the abdomen to get a view of the uterus later in pregnancy;

HCG—Human chorionic Gonadotropine, the hormone produced by the placenta in early pregnancy;

threatened miscarriage—any bleeding in early pregnancy is treated as such;

blighted ovum—when a gestational sac is truly empty;

retroverted uterus—when a uterus tilts back towards the spine;

subchorionic hematoma—bleeding in or under the placenta, usually heals on its own, especially with maternal bedrest, can result in placental abruption where the placenta separates, ending the pregnancy or causing preterm labor;

D and C—dilation and curettage, a procedure where the cervix is dilated and tissue in the uterus is scraped out;

D and E—dilation and evacuation, a procedure where the cervix is dilated and the tissue in the uterus is vacuumed out;

ectopic pregnancy—when a pregnancy begins to grow outside the uterus, most commonly in the fallopian tubes, most always dangerous to mother and fatal to baby, usually treated by surgery or feticidal medications; and

hemorrhaging—severe bleeding.

Works Cited
American Pregnancy Association, (2009). Vanishing Twin Syndrome. American Pregnancy Association, Retrieved August 1, 2009, from http://www.americanpregnancy.org/multiples/vanishingtwin.html
Davis, Pamela M. (1991 October ). Determining the viability of early pregnancies: two case reports. Journal of Family Practice, Retrieved August 1, 2009, from http://findarticles.com/p/articles/mi_m0689/is_n4_v33/ai_11492546/
DiLeo, MD, Dr. Gerard M. (2009). Causes of Bleeding in the First Trimester. Babyzone.com, Retrieved August 1, 2009, from http://www.babyzone.com/pregnancy/trimesters/first_trimester/article/bleeding-first-trimester-causes-pg2
Frye, Anne (2009). HCG Levels in Pregnancy. bobrow.net, Retrieved August 1, 2009, from http://www.bobrow.net/kimberly/birth/hcglevels.html
Hematoma Specialists, (2009). Subchorionic Hematoma. HematomaTreatment.com, Retrieved August 1, 2009, from http://hematomatreatment.com/subchorionic-hematoma/
Kay (2008, June 4). Find a misdiagnosed story fast!. Retrieved August 4, 2009, from The Misdiagnosed Miscarriage Site Web site: http://www.misdiagnosedmiscarriage.com/
Medicine Online (2009). Qualitative Pregnancy Test, Blood – Serum Pregnancy Test, Qualitative. Medicine Online, Retrieved August 1, 2009, from http://www.medicineonline.com/topics/Q/2/Qualitative-Pregnancy-Test-Blood/Serum-Pregnancy-Test-Qualitative.html
Merk Manuals Online Medical Library, (2009). Placenta Previa. Abnormalities of Pregnancy, Retrieved August 1, 2009, from http://www.merck.com/mmpe/sec18/ch263/ch263i.html
Westcliff Medical Laboratories (2009). Quantitive Beta-Hcg Chart . Retrieved August 1, 2009, from http://www.westclifflabs.com/

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