Ealing HospitalNHS Trust

Early pregnancy diagnosis at first presentation C H A R I T Y K H O O , A I K A T E R I N I I A T R O P O U L O U , S A I R A H U S S A I N , L I N D A F A R A H A N I , T A N T O H L I C KDepartment of Obstetrics & Gynaecology, Ealing Hospital NHS Trust, London, United Kingdom

INTRODUCTION Pain and bleeding in early pregnancy is common, but often seen as a sign

of pregnancy loss which has significant psychological morbidity for not

only the potential mother but also the father 1, 2. Couples attending early

pregnancy unit (EPU) are often anxious for information about their likely

outcome. We sought to determine the distribution of EPU diagnoses at

the initial visit as well as their final diagnoses.

METHODSAll patients seen in EPU in 2010 were identified on Viewpoint eRecords.

2,380 scans were performed of which 9 were excluded because they

were gynaecological referrals, and a further 9 were excluded due to

incomplete diagnostic or clinical documentation to verify the diagnosis. A

total of 2,362 scans were analysed.

Table 1. Comparison of mean ± SD of maternal age, gestational age (GA), and median (range) of parity, gravidity, and frequency of pain and or bleeding as presenting complain among gestations by final outcome

References 1: Lok IH, Neugebauer R. Psychological morbidity following miscarriage. Best Pract Res Clin Obstet Gynaecol 2007 ;21(2):229-47. 2: Kong GW, Chung TK, Lai BP, Lok IH. Gender comparison of psychological reaction after miscarriage-a 1-year longitudinal study. BJOG 2010;117(10):1211-9. 3: Sagili H, Mohamed K. Pregnancy of unknown location: an evidence-based approach to management. The Obstetrician & Gynaecologist 2008; 10:224-230

RESULTS A total of 2,362 scans were analysed for the 1,577 gestations presenting

to EPU. This included 141 referred from antenatal clinic or main

ultrasound department. These 1,550 women include 25 (1.6%) twin

gestations and 1 (0.06%) triplet gestation. Of these women, 29 presented

following evacuation of retained products of conception or termination

of pregnancy, and 15 were not pregnant. These 44 gestations were

excluded and the remaining 1,533 (97.2%) were analysed and the results

are shown in figure 1.

The majority (80%) will have their gestation localised in the uterine

cavity, of which 61.5% will be demonstrated to be viable and 18.1% non-

viable. The majority (70%) of ectopic pregnancies are diagnosed at the

first visit. One of the 29 gestations initially classified as ectopic pregnancy

was suspected to be an interstitial pregnancy; this was reviewed and re-

classified as a lateral intrauterine pregnancy. One case of heterotropic

pregnancy was found during follow-up of an intrauterine pregnancy. No

cases of EP was missed by misclassifying them as miscarriage.

Forty-five gestations were lost to follow-up. Of the remaining 1,488

gestations, the eventual diagnoses were 873 viable intrauterine

pregnancy (vIUP), 379 miscarriage, 196 failed pregnancy of unknown

location (PUL) and 40 ectopic pregnancies (EP). The demographics of

these final gestation outcomes are as shown in table 1.

Correspondence: tohlick.tan@nhs.net

CONCLUSIONS Almost 1 in 2 presentations to EPU can be reassured with a vIUP. Of the

about 1 in 6 PUV and 1 in 6 PUL, 2 in 6 will also eventually have a vIUP.

However, about 1 in 6 will either be told of their miscarriage or less

commonly an EP at their first visit. In the cohort of women presenting to

EPU about 2 in 5 presentations to EPU will experience a pregnancy loss,

including 3% of the women initially diagnosed with a vIUP.

EP accounts for 2.7% of the final diagnoses with the majority being

diagnosed at presentation. Our PUL rate of 18% is consistent with the 8-

31% reported in the literature despite our use of a more stringent criteria

described in our poster abstract A0887 3.

Figure 1. Initial and final diagnoses of presentations to EPU

1,533 Gestations

1,227 Intrauterine(80.0%)

754 Viable IUP

731 Viable IUP*

23 Miscarriage

251 PUV

111 Viable IUP

96 Miscarriage

1 Heterotophic EP

43 No f/u

222 Miscarriage

222 Miscarriage

277 PUL(18.1%)

68 Intrauterine

30 Viable IUP

38 Miscarriage 196 Failed PUL

11 EP

2 No f/u

29 EP(1.9%)

1 Lateral IUP

28 EP

Viable IUP Miscarriage Failed PUL Ectopic pregnancy

n 872 (58.7%) 379 (25.5%) 196 (13.2%) 40 (2.7%)

Maternal age, year 29.2 ± 5.9 32.0 ± 6.1 30.8 ± 6.9 31.3 ± 5.1

GA (LMP), week 9.8 ± 6.2 10.5 ± 4.2 8.4 ± 2.4 7.2 ± 2.7

GA (USS), week 9.5 ± 5.2 10.2 ± 4.2 - -

Parity 0 (0-8) 1 (0-9) 1 (0-9) 0 (0-4)

Gravidity 2 (1-15) 2 (1-13) 2 (1-10) 2 (1-12)

Pain 70.3% 58.0% 81.1% 80.0%

Bleeding 56.7% 69.7% 94.9% 80.0%