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Chapter 76 PELVIC INFLAMMATORY DISEASE538
women with mild PID treated with ceftriaxone 250 mg intramuscularly and randomized to
azithromycin 1 g orally once weekly for 2 weeks, versus doxycycline 200 mg per day for
14 days, results demonstrated a 90.3% versus 72.4% cure rate for azithromycin versus
doxycycline.
12. Does the presence of an intrauterine pregnancy effectively rule out PID?
A common misconception is that PID cannot occur in a pregnant woman. Although rare, it
most commonly occurs in the first trimester in primigravida patients. Infection can take place
concurrently with fertilization or throughout the first trimester, after which the uterine cavity is
obliterated by the pregnancy.
13. Does a history of tubal ligation preclude the diagnosis of PID?
Bilateral tubal ligation (BTL) does not preclude PID. Histologically, inflammation occurs both
proximal and distal to the occlusion site. Tubo-ovarian abscesses have been reported up to
20 years following ligation.
14. What is the appropriate follow-up for patients with PID?
Patients treated as outpatients need close follow-up. Response to treatment should be
assessed within 48 to 72 hours. For reliable patients, a phone follow-up may suffice. For
all patients, a test of cure by repeat examination and cervical cultures is recommended
2 to 4 weeks after the initial intervention.
15. Summarize the principles of management of acute PID.
n
Rule out pregnancy.
n
Maintain a low level of suspicion for PID as the consequences of undiagnosed PID include
infertility and chronic pelvic pain.
n
Treat early with broad spectrum antibiotics if PID is suspected.
n
Recommend all patients with PID be tested for other sexually transmitted diseases,
particularly syphilis, Hepatitis B and C, and HIV.
n
Inform the patient that her partner(s) also need to be treated to prevent reinfection.
KEY POINTS: PELVIC INFLAMMATORY DI SEASE
1. Maintain a high suspicion for PID in any patient younger than age 25 with pelvic pain.
2. Although early diagnosis and treatment can prevent significant morbidity, there are no
historical, physical, or laboratory findings that can conclusively diagnose PID.
3. Most cases of PID are polymicrobial, requiring broad spectrum antibiotics for treatment.
4. Abnormal uterine bleeding may be the only sign of PID.
5. Neither pregnancy nor tubal ligation excludes a diagnosis of PID.
ACKNOWLEDGMENT
The editors gratefully acknowledge the contributions of Alexander T. Trott, MD, author of this
chapter in the previous edition.
Chapter 76 PELVIC INFLAMMATORY DISEASE 539
BIBLIOGRAPHY
1. CDC Sexually Transmitted Diseases Treatment Guidelines 2006. MMWR 4;55 (RR11):1, 2006.
2. Chandra A, Martinez GM, Mosher WD, et al: Fertility, family planning and reproductive health of US women:
data from the 2002. National Survey of Family Growth. Vital Health Stat 23(25): 1–160, 2005.
3. Haggerty CL, Peipert JF, Weitzen S, et al: Predictors of chronic pelvic pain in an urban population of women
with symptoms and signs of pelvic inflammatory disease. Sex Transm Dis 32(5): 293–299, 2005.
4. Heinonen PK, Leinonen M: Fecundity and morbidity following acute PID treated with doxycycline and
metronidazole. Arch Gynecol Obstet 268:284–288, 2003.
5. Levgur M, Duvivier R: PID after tubal sterilization: a review. Obstet Gynecol Surv 55:41–50, 2000.
6. Savaris RF, Teixeira LM, Torres TG, et al: Comparing ceftriaxone plus azithromycin or doxycycline for pelvic
inflammatory disease: a randomized controlled trial. Obstet Gynecol 110 (1):53–60, 2007.
7. Sellors J, Mahony J, Goldsmith C, et al: The accuracy of clinical findings and laparoscopy in pelvic
inflammatory disease. Am J Obstet Gyecol 14:113–120, 1991.
540
SEXUAL ASSAULT
CHAPTER 77
Katherine M. Bakes, MD, and Bernadine L. Mellinger, BSN, RN, SANE-A, CFN
1. What is the definition of sexual assault?
Definitions may vary from state to state, but sexual assault generally refers to any deliberate
sexual contact to areas of the genitalia, anus, or mouth, or manual penetration of the victim’s
body by way of force, threatened physical abuse, or abuse of authority or when the victim
does not or cannot consent. Individuals who have an impaired mental function due to alcohol,
drugs, sleep, or unconsciousness are unable to give consent by definition. The more
traditional term rape is defined as forced vaginal, anal, or oral penetration. This definition of
sexual assault includes attempted rape of male, female, heterosexual, and homosexual
victims.
2. How common is sexual assault?
Sexual assault is one of the most under-reported crimes; research indicates that only 40% of
sexual assaults are reported to law enforcement. In 2007, 248,300 men and women became
victims of rape, attempted rape, or sexual assault and reported to law enforcement. That
means every 2 minutes, somewhere in the United States, someone is sexually assaulted. One
in 6 women and one in 33 men will report a completed or attempted rape during their lifetime.
Women ages 18 to 26 are four times more likely to be sexually assaulted. Of women who
report being raped, 54% were younger than the age of 18 years when they were victimized.
Rape in the United States has been termed a tragedy of youth. Women who are sexually
assaulted as children and adolescents are at greater risk of being sexually assaulted as an
adult. Although most victims of sexual assault are women, men can be assaulted by other
men, and occasionally women perpetrate sexual assaults against other women or men. The
vast majority of sexual assaults (72%) are perpetrated by someone whom the victim knows,
with only 6% of those perpetrators spending time in jail.
3. What role does a medical provider have in cases of alleged rape?
Rape is a legal term, and usually law enforcement is requesting for evidence to be gathered.
The ED is the most common place for a sexual assault victim to present for acute medical
care and forensic evidence gathering. 32% of women older than 18 years who are sexually
assaulted report being injured in the assault and 36% seek some type of medical treatment,
which includes care for traumatic injuries. Always remember that the physician’s primary
responsibility is to provide for the patient’s physical and psychological well-being first; then,
if the patient consents, to provide police with corroborative forensic evidence. Victims should
be encouraged to undergo an evidentiary examination as soon as possible because critical
evidence may be lost if this examination is delayed. The victim may later choose not to
proceed through the criminal justice system because collection of forensic evidence does not
commit him or her to seek prosecution.
Many hospitals now have Sexual Assault Nurse Examiners (SANE) who have been
specially trained to care for these victims of violence. These nurses are educated and trained
to complete a comprehensive and compassionate medical-legal examination. If a SANE is not
available, a comprehensive ED sexual assault protocol that addresses medical care and the
evidentiary collection is necessary for optimal patient care.
Chapter 77 SEXUAL ASSAULT 541
4. What information should be elicited in the patient history?
n
Information regarding the patient’s general health, medications, and allergies should be
obtained along with a complete gynecologic history, including birth control usage, date
and time of last consensual intercourse, last menstrual period, and history of recent
gynecologic symptoms before the assault. Questions as to body surface injuries prior to
the assault should also be documented.
n
A directed history of the assault includes the date, time, and location of the assault;
information concerning the relation the victim had with the assailant; and the type and
details of the sexual acts, including type of force or threats used. The history must be
obtained in a private setting; law enforcement personnel should not be present.
5. What should comprise the physical examination?
Rape is a crime of violence and control, not a crime of passion. The purpose of the physical
examination is to detect injuries requiring treatment and to record and gather forensic
evidence for prosecution. A complete head-to-toe medical examination should be done,
regardless of whether law enforcement has requested a forensic examination and regardless
of whether the patient has consented to a forensic examination. General body trauma occurs
more frequently than genital trauma. Injuries may include abrasions and bruises on the arms,
head and neck, signs of restraint (such as rope burns or mouth injuries), broken teeth,
fractured nose or jaw from being punched or slapped, muscle soreness, or stiffness from
restraint in positions allowing sexual penetration. These injuries should be documented
(i.e., size, color, and shape) on a body diagram with photographic documentation if possible.
The gynecologic examination should include a thorough search for contusions, abrasions,
lacerations, bleeding, or tenderness. Most semen or saliva will fluoresce under a Wood’s
lamp. Toluidine blue dye does not reveal injury that is not visible to the naked eye but
highlights genital injuries such as tears or abrasions. A colposcopic examination may help to
identify outer genital and cervical injuries, and if possible, photographs of the genital area
should be taken. A careful rectal examination should be done in cases of rectal penetration,
and if blood is present, anoscopy or sigmoidoscopy should be done to identify internal
injuries.
6. What evidence is gathered as part of the forensic examination?
The forensic evidence may be divided into four categories: control samples from the victim,
evidence that might identify the assailant, evidence or proof of recent sexual contact, and
evidence or proof of force or coercion (Table 77-1).
7. What laboratory studies are indicated?
A urine or serum pregnancy test will rule out a preexisting pregnancy. If pregnant, the patient
should be reassured that this pregnancy was not the result of the assault. The routine
collection of gonorrhea or chlamydial cultures is debatable. From a medical-legal perspective,
positive cultures indicating preexisting sexually transmitted diseases (STDs) have been
used by the perpetrator’s defense attorney as evidence of the victim’s sexual promiscuity.
A preexisting infection is present in approximately 5% of assault victims, the same rate as in
the general population. It is reasonable to only test those patients with signs or symptoms of
infection and presumptively treat all victims for possible exposure. If the victim does not wish
to receive prophylactic antibiotics in the ED, Chlamydia and gonorrhea cultures should be
repeated in 2 weeks.
8. What about blood alcohol levels and tests for drug use?
In general, routine drug screens and routine alcohol levels are not recommended; proof of
intoxication or drug use may or may not be used against the victim in a court of law, however,
collecting blood or urine may help to prove the victim was too intoxicated to consent. If
tests are medically indicated and will influence your treatment (such as a patient with an
unexplained altered mental status, or unexplained tachycardia), then laboratory testing may
be indicated.
Chapter 77 SEXUAL ASSAULT542
9. What historical features might indicate a drug-facilitated rape?
A history of a period of amnesia or a history of being out drinking and then suddenly feeling
very intoxicated should raise concerns about a drug-facilitated sexual assault (DFSA).
Sometimes the patient simply relates a history of waking up without clothes on, unsure of
what occurred, with genital or pelvic soreness. In these situations, urine and blood should be
obtained for drug testing. This testing can be collected in the ED and handed directly to law
enforcement to preserve chain of evidence, and victims should be informed that any previous
volitional, recreational drug use (such as cocaine or marijuana) may also be revealed in the
toxicologic screening. The samples should be refrigerated after receipt by law enforcement to
preserve the detection of drugs of abuse. Conviction of a DFSA increases the legal penalties
significantly.
10. What are the most common STDs that may be contracted as a result of a
sexual assault?
Sexual assault victims are at risk of contracting chlamydial infection, gonorrhea, bacterial
vaginosis, hepatitis B, and HIV. The risks of contracting a new chlamydial, gonorrheal, or
bacterial vaginosis infection as the result of sexual assault are hard to estimate; risk varies
according to geographical area and type of assault. In general, the risk of contracting
chlamydial infection or gonorrhea is 4% to 17%, and the risk of contracting bacterial
vaginosis is slightly higher. Hepatitis B is efficiently transmitted via sexual contact.
Adapted from Patel M, Minshall L: Management of sexual assault. Emerg Med Clin North Am 19:817–831,
2001; and Feldhaus KM: Female and male sexual assault: In Tintinalli JE, Kellen GB, Stapcznski JS,
editors: Emergency medicine: a comprehensive study guide, ed 6, New York, 2004, McGraw-Hill,
pp 1851–1854.
TABLE 77-1. FORENSIC EVIDENCE KIT CONTENTS
Control samples from victim
n
Head hair samples
n
Saliva sample
n
Pubic hair samples
Samples to identify assailant
n
Skin swabbing for assailant’s saliva or sperm
n
Fingernail scrapings or clipping (from victim)
n
Pubic hair combing
n
Trace evidence (such as stray hair, bits of clothing, foreign matter)
Evidence for proof of recent sexual contact:
n
Oral, vaginal, or anal swabs for semen
n
Skin swabbing for saliva or semen
n
Any tampons, vaginal pads, or condoms left in vaginal vault if present
Evidence for proof of force or coercion:
n
Documentation and photographs of injuries found on examination
n
Fingernail scrapings or clippings
n
Urine or blood for toxicologic testing (if drug-facilitated sexual assault is suspected)
n
All clothing
Chapter 77 SEXUAL ASSAULT 543
11. Is empirical antibiotic treatment of sexual assault victims indicated?
How about vaccinations?
Because of historically poor follow-up rates by sexual assault victims, along with the significant
risk of contracting a new STD, prophylaxis should be offered to all victims. Effective regimens
include azithromycin, 1 gm orally in a single dose, or doxycycline, 100 mg orally twice a day
for 7 to 10 days for chlamydial prophylaxis; ceftriaxone, 125 mg intramuscularly in a single
dose or cefixime 400 mg orally in a single dose for gonorrhea coverage; and a single 2 g oral
metronidazole dose to treat Trichomonas and bacterial vaginosis. The Centers for Disease
Control and Prevention (CDC) also recommends that pregnant patients should receive
ceftriaxone 125 mg intramuscularly (IM) in a single dose (avoid quinolones and tetracyclines)
for gonorrhea coverage, as well as erythromycin base 500 mg four times a day (qid) for 7 days
or amoxicillin 500 mg three times a day (tid) for 7 days to cover Chlamydia. Contracting
bacterial vaginosis during pregnancy carries a risk of premature rupture of membranes,
preterm labor, and chorioamnionitis; pregnant women should be encouraged to follow up
with gynecology and receive treatment if they develop bacterial vaginosis.
The CDC also recommends that hepatitis B vaccine be administered at the time of the
initial examination if victims have not been previously vaccinated. Follow-up doses of vaccine
should be administered 1 to 2 and 4 to 6 months after the first dose.
12. What is the risk of pregnancy after sexual assault?
Although the risk of pregnancy after an isolated sexual encounter during nonfertile periods
of the menstrual cycle is thought to be less than 1%, it is significantly higher at midcycle.
Approximately 5% of all sexual assault victims become pregnant as a result of the assault.
The presence of a preexisting pregnancy must be identified in the ED.
13. What are the current options for pregnancy prophylaxis?
When a preexisting pregnancy has been ruled out, postcoital contraceptives can be used to
prevent pregnancy by inhibiting or disrupting ovulation or inhibiting fertilization or
implantation. Emergency contraception is not effective once implantation has occurred, and it
will not disrupt an existing pregnancy. These products may be taken up to 5 days after sexual
contact, but because their effectiveness decreases over time, ideally they should be taken
within 72 hours. There are two Food and Drug Administration (FDA)-approved oral products
for postcoital emergency contraception. Preven is a combination of ethinyl estradiol and
levonorgestrel. Plan B contains only levonorgestrel. Common side effects include nausea,
vomiting, and vaginal spotting. The latest research shows that taking both tablets of Plan B
at one time (total of 150 mg levonorgestrel) is as effective as separating the two tablets by
12 hours. The failure rate with Plan B is less than 2%. If a dedicated emergency contraceptive
product is not available, a levonorgestrel-containing oral contraceptive pill, such as Ovral,
may be used, dosed as two tablets of Ovral now, two in 12 hours.
14. What are special characteristics of the male sexual assault victim?
The male sexual assault victim should be treated similarly to a female victim. Special attention
should be paid to the mouth, genitalia, anus, and rectum. Men represent approximately 5% of
reported sexual assault victims.
15. Discuss the special characteristics of pediatric sexual assault.
In pediatric sexual assault, the assailant is often known to the victim, and there is often a
history of repetitive assaults. In addition to documenting signs of acute trauma, the physician
should look for signs of recurrent abuse, such as healed hymenal tears, a large vaginal
opening, vaginal discharge, or relaxed rectal sphincter tone. The gynecologic examination
should take into account the nature of the assault and the age of the child, keeping in mind
the exquisite sensitivity of the prepubertal vaginal introitus and hymen. In the evaluation of a
small child in whom a speculum examination is indicated, a nasal speculum may be used in
place of a vaginal speculum. If possible, this examination is best performed in conjunction
with physicians who specialize in child abuse. Sometimes the vaginal or rectal examination
Chapter 77 SEXUAL ASSAULT544
must be done under general anesthesia because of the emotional state of the child. The child
should be protected from further abuse by admission to the hospital or by immediate referral
to the appropriate social service agency.
16. Should pediatric patients be given prophylactic antibiotics?
Prophylactic antibiotics are not generally indicated when sexual abuse of children is
suspected. The baseline infection rate in children is significantly lower than in adults, and the
presence of an STD in a child is strong evidence that abuse has occurred. It is important to
document the presence of the infection before treatment. In the child, chlamydial and
gonorrhea cultures should be obtained from the urine or vagina instead of the cervix.
17. State the important aspects of follow-up care for any victim of sexual assault.
Follow-up medical care should ensure that any physical injuries have healed properly (follow
up photographs may be taken), adequate pregnancy prophylaxis has been administered, STDs
have been treated properly, and the victim has accessed supportive counseling. Provision of
written aftercare instructions and information on community resources is essential.
18. What types of emotional trauma might sexual assault victims experience?
The development of a posttraumatic stress disorder, manifested by sleep disturbances, feelings
of guilt, memory impairment, and detachment from the world and others may occur in the days
to weeks following the assault. Long-term psychological sequelae in the form of rape trauma
syndrome may also occur. Many communities have rape crisis centers with social workers and
volunteers who are trained to provide counseling for sexual assault survivors. Sexual assault
response teams have been organized in other areas to provide a coordinated approach to the
sexual assault victim, including emotional support after the event. Physicians should be aware
of the availability of such services so that they can recommend them to their patients.
19. My patient is terrified of contracting HIV after her sexual assault.
What do I do now?
Offer nonoccupational postexposure prophylaxis (nPEP).
20. What is nPEP?
nPEP refers to the provision of postexposure antiretroviral therapies for individuals who are
exposed to potentially infected blood or bodily fluids from sexual contact, from injection drug
use, or in other nonoccupational settings (i.e., non-health care, sanitation, public safety, or
laboratory employment settings).
21. What is the risk of acquiring HIV after a sexual assault?
The estimated risk is dependent on the HIV status of the assailant, the type of sexual contact,
and the amount of mucosal trauma involved. The HIV status of the source should be
considered—is the assailant known to be HIV positive? Is the assailant known to be from a
group with a high prevalence rate of HIV (i.e., injection drug users, commercial sex workers,
or homosexual or bisexual men)? Studies in prison populations reveal that HIV infection
rates are higher in male sexual assailants than in the general male population (1% vs. 0.3%).
In most cases of sexual assault, the HIV status of the assailant will not be known. Genital
trauma, bleeding, and inflammation associated with sexual assault increase the risk of HIV
transmission. In general, receptive anal intercourse carries a risk of seroconversion of 50 per
10,000 exposures. In comparison, a percutaneous needle stick from an infected source
carries a 30 per 10,000 risk of contracting HIV. The risk of contracting HIV following
receptive penile-vaginal intercourse is 10 per 10,000.
22. How exactly do I provide nPEP for my patient?
Baseline HIV testing should be performed on the victim, preferably with an FDA-approved
rapid-test kit (results available within 1 hour). nPEP should begin within 72 hours of exposure,
the sooner the better. If more than 72 hours have lapsed since the assault, the risks of
Chapter 77 SEXUAL ASSAULT 545
antiretroviral therapies may outweigh the benefit. No evidence indicates that any specific
antiretroviral medication or combination of medications is optimal for use as nPEP. Based
on the degree of experience with certain agents, there are preferred regimens, including
nonnucleoside reverse transcriptase inhibitor (NNRTI)-based therapies and protease
inhibitor (PI)-based therapies.
n
Preferred NNRTI regimens include efavirenz (Sustiva) plus lamivudine (Epivir, 3TC) or
emtricitabine plus zidovudine or tenofovir.
n
PI regimens include lopinavir/ritonavir (coformulated in one tablet as Kaletra) plus
zidovudine (AZT, Retrovir) plus either lamivudine or emtricitabine.
Efavirenz should be avoided in pregnant women and women of child-bearing potential.
Regardless of the regimen chosen, the exposed person should be counseled about the
potential associated side effects and adverse events that require immediate medical attention.
The use of medications to treat symptoms (e.g., antiemetics or antimotility agents) might
improve medication compliance. A 3- to 5-day starter pack is recommended with a follow-up
visit scheduled to review the results of HIV testing (if a rapid test was not used), review
baseline laboratory data, discuss medication side effects, and change therapies if needed.
A full 28-day course of medications should be provided at that time.
KEY POINTS: CARE OF THE SEXUAL ASSAULT VICTIM
1. First and foremost, care for the victim’s medical and emotional needs.
2. Collection of forensic evidence is requested by law enforcement and may not be performed
without the victim’s consent.
3. Victims must be told of the options they have as to reporting and evidence collection. They
can report to law enforcement and have evidence collected, they may decline reporting to law
enforcement and have evidence collection, or they can decline to report and decline evidence
collection but choose only treatment.
4. All victims should be offered prophylactic antibiotics for sexually transmitted diseases.
5. Women of child-bearing age should be informed about emergency contraception; if it is not
offered to the victim at the hospital, a referral should be made so that the patient may receive
it in a timely manner.
6. Written referral to community resources for post-assault counseling is critical.
WEBSITES
Antiretroviral postexposure prophylaxis: www.cdc.gov/mmwr/preview/mmwrhtml/rr5402a1.htm
Facts about sexual assault: www.rainn.org/statistics
National Crime Victimization Survey 2007: www.ojp.usdoj.gov/bjs/pub/pdf/cv07.pdf
Prevalence, incidence, and consequences of violence against women:
http://ncjrs.org/pdffiles/172837.pdf
Sexually transmitted diseases treatment guidelines: www.cdc.gov/std/treatment/2006/
sexual-assault.htm
Sexual violence fact sheet: www.cdc.gov/ncipc/factsheets/svfacts.htm
Chapter 77 SEXUAL ASSAULT546
BIBLIOGRAPHY
1. Anglin D, Spears KL, Hutson HR: Flunitrazepam and its involvement in date or acquaintance rape. Acad Emerg
Med 4:323–326, 1997.
2. Cheng L, Gulmezoglu AM, Oel CJ, et al: Interventions for emergency contraception. Cochrane Database Syst Rev
3:CD001324, 2004.
3. Feldhaus KM: Female and male sexual assault. In Tintinalli JE, Kellen GB, Stapcznski JS, editors: Emergency
medicine: a comprehensive study guide, ed 6th, New York, 2004, McGraw-Hill, pp 1851–1854.
4. Patel M, Minshall L: Management of sexual assault. Emerg Med Clin North Am 19:817–831, 2001.
5. Resnick HS, Holmes MM, Kilpatrick DG, et al: Predictors of post-rape medical care in a national sample of
women. Am J Prev Med 19:214–219, 2000.
6. Riggs N, Houry D, Long G, et al: Analysis of 1.076 cases of sexual assault. Ann Emerg Med 35:358–362, 2000.
ACKNOWLEDGMENT
The editors gratefully acknowledge the contributions of Kim M. Feldhaus, MD, author of this chapter
in the previous edition.
547
SPONTANEOUS ABORTION, ECTOPIC
PREGNANCY, AND VAGINAL BLEEDING
CHAPTER 78
Brandon H. Backlund, MD, FACEP
1. What is spontaneous abortion or miscarriage?
Spontaneous termination of intrauterine pregnancy (IUP) before achieving fetal weight or
maturity compatible with survival (less than 20–22 weeks’ gestation, or fetal weight less
than 500 g).
2. State the incidence and timing of spontaneous miscarriage.
Ten percent to 20% of clinically recognized pregnancies less than 20 weeks miscarry; 80% of
these occur in the first 12 weeks of gestation. Approximately 70% of all spontaneous
abortions occur before pregnancy is clinically detected.
KEY POINTS: MOST COMMON CAUSES OF SPONTANEOUS
ABORTIONS
1. First 4 to 8 weeks of gestation: abnormal development of the zygote with chromosomal
abnormalities in 50% to 60% of spontaneous abortions
2. Later in the first trimester:
• Isolated chromosomal abnormalities
• Maternal factors (insufficient progesterone support, alcohol use, cocaine use, tobacco use,
nonsteroidal anti-inflammatory drug [NSAID], or caffeine use)
• Structural uterine abnormalities
3. What are the five types of miscarriage or abortion?
n
Threatened abortion: A pregnant patient within the first half of pregnancy with vaginal
bleeding and a closed internal cervical os on bimanual examination. Cramping abdominal,
pelvic, or back pain may also be present.
n
Inevitable abortion: Findings of a threatened abortion, but with an open internal cervical os.
n
Incomplete abortion: A miscarriage in progress. Only parts of the products of conception
have been passed and may be visible in the cervical os or the vaginal canal.
n
Complete abortion: All products of conception have been passed. Pain and significant
bleeding should stop after a complete abortion.
n
Missed abortion: Retention of a nonviable IUP within the uterus. Products of conception
are demonstrable, but fetal development has ceased, no cardiac activity is visible, the
cervical os is closed, and spontaneous passage has not occurred after 4 to 8 weeks.
4. Describe the early sonographic findings in a healthy pregnancy.
n
Gestational sac: One of the earliest findings of normal pregnancy, seen at about 4 to
5 weeks gestational age (GA) by transvaginal ultrasound. This is a well-circumscribed fluid
collection within the endometrial cavity. A true gestational sac is surrounded by two layers
of tissue, forming the “double decidual” sign: an inner layer, called the decidua capsularis,