A 37-year-old woman, gravida 2 para 1, at 8 weeks gestation comes to the office for a follow-up visit. Earlier in the pregnancy, the patient had nausea and breast tenderness that resolved several days ago. She has no other concerns. At her initial prenatal visit a week ago, ultrasound revealed an intrauterine gestational sac with a yolk sac but no fetal pole. β-hCG level at that visit was 27,325 IU/L. She is taking a prenatal vitamin and does not use tobacco, alcohol, or illicit drugs. Current blood pressure is 140/80 mm Hg and pulse is 68/min. BMI is 23 kg/m². Pelvic examination reveals a closed cervix and no vaginal discharge or bleeding. Bimanual examination reveals a normal-sized, retroverted uterus with no cervical motion or adnexal tenderness. A transvaginal ultrasound is repeated and is unchanged from the prior visit. β-hCG level is now 25,659 IU/L. Which of the following is the most likely diagnosis?

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11ec25c8_da0d_3c6a_bc81_b31a2044a6de_MD0003_00 This patient has a missed abortion, an intrauterine pregnancy demise at <20 weeks gestation prior to expulsion of products of conception. Patients may be asymptomatic or have decreased pregnancy symptoms (eg, nausea, breast tenderness). Physical examination reveals a closed cervix. Risk factors for a spontaneous abortion include advanced maternal age due to its associated increased risk of fetal chromosomal abnormalities. Ultrasound findings in a missed abortion include an embryo without cardiac activity or an empty gestational sac without a fetal pole (eg, no embryo). Some early pregnancies can present without a fetal pole. Viability is determined with repeat ultrasounds and serial β-hCG levels. Repeat ultrasounds of a viable pregnancy reveal continued embryonic development. Serial β-hCG levels normally increase until the end of the first trimester; decreasing β-hCG levels indicate a demise and exclude a normal pregnancy (Choice E). (Choice A) An ectopic pregnancy is excluded in this patient by the ultrasound finding of an intrauterine gestational sac that contains a yolk sac (eg, early intrauterine pregnancy). (Choice B) A hydatidiform mole is an abnormal gestation that presents with heavy bleeding, a "snowstorm" appearance on ultrasound, and a markedly elevated β-hCG level (>100,000 IU/L). This patient's decreasing β-hCG level makes a hydatidiform mole unlikely. (Choice C) An incomplete abortion presents with pain, bleeding, a dilated cervix, and passage of some products of conception. (Choice F) Threatened abortions present with bleeding and a closed cervix; ultrasound reveals an intrauterine gestation with a normal heartbeat. At 8 weeks gestation, threatened abortions would have increasing β-hCG levels. Educational objective: A missed abortion is a pregnancy loss at <20 weeks gestation prior to expulsion of products of conception. Patients with missed abortions are typically asymptomatic but can present with loss of pregnancy symptoms or light vaginal bleeding. Findings include a closed cervix, decreasing β-hCG levels, and an ultrasound revealing a nonviable (eg, no fetal heartbeat) intrauterine pregnancy. References: Contemporary management of early pregnancy failure. (http://www.ncbi.nlm.nih.gov/pubmed/17304025) Assessment and management of bleeding in the first trimester of pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/19879521)

A 37-Year-Old Woman, Gravida 2 Para 1, at 8 Weeks