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FETAL heart motion is an impressive sight on ultrasound examination. It is one of the first signs we recognise when we start scanning pregnant patients.
We like to see fetal heart motion; it is usually a cause for celebration. Fetal life is easy to diagnose.
Unfortunately the accurate diagnosis of fetal death can be much more difficult, especially in the first trimester. We all have anecdotes about detecting fetal heart motion in a pregnancy that was misdiagnosed as a miscarriage the day before. And we have all wondered whether the mistake was due to carelessness, inexperience, or a cheap ultrasound machine.
I was once shown a picture of a so-called “missed abortion” which looked more like a spherical ovarian cyst surrounded by follicles. On trans-vaginal scanning the perfectly formed early intra-uterine pregnancy was found in a very retroverted uterus somewhere in the distance.
It goes without saying that the misdiagnosis of fetal demise can lead to serious unintended consequences including the evacuation of a much-wanted pregnancy.
So it was with great interest that I read the multi-centre observational studies that followed women with an intra-uterine pregnancy of unknown viability who had a follow-up scan 7-14 days later.
The most sobering finding was that when a 4-5 mm embryo had an absent heart beat, 8.3% were subsequently found to be ongoing pregnancies. This justifies the previous Royal College of Obstetricians and Gynaecologists and Australian Society of Ultrasound in Medicine guidelines which recommend that the diagnosis of fetal demise not be made until absent heart motion is noticed in a fetus with a crown rump length (CRL) measurement of 6mm or greater.
However, another study in the same journal demonstrated significant inter-observer variability in CRL measurements and greater variation in early embryonic growth than had been assumed. They recommended a more conservative approach to the diagnosis of early pregnancy loss.
This resulted in the RCOG amending its guideline, The Management of Early Pregnancy Loss, by recommending that ultrasound diagnosis of miscarriage only be considered with a mean gestation sac diameter >/= 25mm (with no obvious yolk sac), or with a fetal pole with CRL >/=7mm (the latter without evidence of fetal heart activity), and that a trans-vaginal ultrasound scan be performed in all cases.
The guideline now says if there is any doubt, a repeat scan should be performed at least one week after the initial scan before any medical or surgical measures are undertaken for uterine evacuation. No growth in gestation sac size or CRL measurement is strongly suggestive of a non-viable pregnancy in the absence of embryonic structures.
The Australian Society of Ultrasound in Medicine recommends caution.
Misdiagnosis of a non-viable pregnancy may be more common than we dare to ponder. After all, most would be curetted away leaving no evidence of the error.
We clearly need to be cautious in our diagnosis of early fetal demise, and remember that in a clinically stable patient there is usually little to lose by rescanning in a week to determine viability. This waiting can be frustrating for some women, especially for those on fertility treatment programs. However, there is currently no alternative.
Making a “speedy” diagnosis could be fatal — quite literally.
More difficult is the task of educating the wide range of ultrasound users in Australia — radiologists, obstetricians, accident and emergency physicians, GPs, registrars, sonographers, early pregnancy assessment clinic nurses, IVF unit nurses and midwives. Some of these users have little training in ultrasound and no formal assessment of their skills.
Ultrasound is thought to be safe. But its real danger to a fetus is not exposure to bio-effects. It is the risk of a false-positive diagnosis which can lead to an inappropriate intervention.
Beware the misdiagnosis of miscarriage: “First do no harm.”
Dr Philippa Ramsay is the director of Ultrasound Care, Sydney, and clinical lecturer at Royal Prince Alfred Hospital and the University of Sydney.
Posted 30 January 2012
I’ve been told this week my pregnancy is 100% non viable based on HCG alone. No ultrasound offered. I’m only 4 weeks. No cramping or bleeding.
I asked if there was any chance and the nurse said no.
I have a retroverted uterus and I was told that my baby has no heartbeat today. My story was similar to the first commenter. No bleeding. No physical miscarriage. The “cold” tech just said “I can’t find a heartbeat. I’m sorry.” She tapped my shoulder and exited the room. I was taken to another room where the Nurse Practitioner called the doctor and informed her that I’d had a missed miscarriage and needed a D&C next week. They didn’t offer a second scan. I wonder if I should get a second opinion. Reading this gives me pause!
About 10 years ago I went for an ultrasound at 10-12 weeks. It was a young technician, no doctor present. The session lasted literally less than a minute. In a very cold, clinical voice she said. I can’t find a heartbeat, I’m sorry, the baby is dead. I said are you sure? She said yes, get up and wipe yourself off and go out and pay at the front. Well, can I see the baby? No, we don’t do that. Can I get a photo? No, we don’t provide photos. That was it. I was left alone in the carpark crying and kind of in shock. It never occurred to me that it could have been a misdiagnoses. I trusted that young technician. I never miscarried. A month later a doctor had set up a curette for me. He said it was likely a missed miscarriage? Noone ever double-checked to see if the baby had died. It has just occurred to me that these people may have killed my baby. This is really hard for me to deal with all these years later. Why did I trust that technician????? I also have a retroverted uterus, so maybe that made it more difficult to hear at 10-12 weeks. I just found your article upon doing a search to see if this ever happens. I’m so angry right now.
Is it really possible to miss a heartbeat after 17-18 weeks? Or will no heartbeat at such term automatically indicate a fetal demise? Thank you
I have recently been sent a case of a woman who had bleeding at term The doctor found a woody hard uterus and did an ultrasound which showed no fetal heart motion. The woman had a BMI of 31. The patient went on to deliver a live male infant with poor APGARS- how easy it it to miss a FH at term?
I could not agree more with the comments about diagnosis in early pregnancy on a single ultrasound. The problem is in our society we want an answer now and we want an immediate solution. But even to do nothing is to do something. The conservative (expectant management) approach to failed pregnancies is also an option with most women (some say up to 85%) completing the process without invasive intervention and the associated health care resources. Many well developed European countries take this approach. Serial HCGs are a waste of time except if ectopic is considered. If an early ultrasound is too early or uncertain then repeat ultrasound some time (at least a week later) will either show progress and a live pregnancy or it will show no progress-hence a failed pregnancy. The advantage of this is some will spontaneously miscarry (therefore no intervention) while the others are unlikely to complete the miscarriage in a timely manner and can be offered the surgical approach.
However I do appreciate there are many ways to beat an egg in order to make an omelet.
Like every area of medicine, no single test should be used in isolation. Evidence of foetal viability includes not just ultrasound, but history, examination and quantitative beta hCG. Unless the woman is life-threateningly haemorrhaging or septic, there is no immediate urgency that would delay a thorough evaluation.
I applaud Dr Ramsay’s article and I agree it behoves practitioners to “be in no hurry” when there is any doubt about early pregnancy ultrasound. This implies that “masterly inactivity” is much better practice than unnecessary intervention. Even when the diagnosis of non-viable pregnancy is certain, every women should be offered the “wait and see” approach if the sac size and associated retained trophoblast is not too great. Ultrasound training has been part of the RANZCOG premembership curriculum for some years now, thanks in no small part to those of us who have practised ultrasound diagnosis in our rooms for over 20 years. I encourage GPs to refer to an O&G specialist who offers the “one stop shop” in simple O&G diagnosis.