Early Pregnancy Complications

  • Kayla DeweyEmail author
  • Kathryn Voss
  • Carolyn Phillips


Pregnant patients often present to the emergency department with chief complaints of abdominal pain and/or vaginal bleeding in the first trimester. Complications of early pregnancy are common and include miscarriage and ectopic and heterotopic pregnancy. Missing a life-threatening diagnosis such as ectopic pregnancy is fraught with risk to both patient and provider. The reliability of the discriminatory zone, used to aide in the diagnosis of early pregnancy complications, has recently been called into question. Assisted reproductive technologies to achieve pregnancy are also becoming increasingly common and present unique diagnostic challenges. Emergency physicians must be prepared to evaluate and manage the various complications of early pregnancy.


First trimester Vaginal bleeding Ectopic pregnancy Pregnancy of unknown location Discriminatory zone Transvaginal ultrasound Heterotopic pregnancy Assisted reproductive technology Ovarian hyperstimulation syndrome 


  1. 1.
    Deutchman M, Tubay AT, Turok D. First trimester bleeding. Am Fam Physician. 2009;79:985–94.PubMedGoogle Scholar
  2. 2.
    Crochet JR, Bastian LA, Chireau MV. Does this woman have an ectopic pregnancy? The rational clinical examination systematic review. JAMA. 2013;309:1722–9.CrossRefPubMedGoogle Scholar
  3. 3.
    Kohn MA, Kerr K, Malkevich D, et al. Beta-human chorionic gonadotropin levels and the likelihood of ectopic pregnancy in emergency department patients with abdominal pain or vaginal bleeding. Acad Emerg Med. 2003;10:119–26.CrossRefPubMedGoogle Scholar
  4. 4.
    Marion LL, Meeks GR. Ectopic pregnancy: history, incidence, epidemiology, and risk factors. Clin Obstet Gynecol. 2012;55:376–86.CrossRefPubMedGoogle Scholar
  5. 5.
    Bouyer J, Coste J, Shojael T, et al. Risk factors for ectopic pregnancy: a comprehensive analysis based on a large case-control, population-based study in France. Am J Epidemiol. 2003;157:185–94.CrossRefPubMedGoogle Scholar
  6. 6.
    Barhart KT. Ectopic pregnancy. N Engl J Med. 2009;361:379–87.CrossRefGoogle Scholar
  7. 7.
    Houry D, Keadey M. Complications in pregnancy part I: early pregnancy. Emerg Med Pract. 2007;9(6):1–28.Google Scholar
  8. 8.
    Mateer JR, Valley VT, Aiman EJ, et al. Outcome analysis of a protocol including bedside endovaginal sonography in patients at risk for ectopic pregnancy. Ann Emerg Med. 1996;27:283–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Dart R, McLean S, Dart L. Isolated fluid in the cul-de-sac: how well does it predict ectopic pregnancy? Am J Obstet Gynecol. 2000;185:522.Google Scholar
  10. 10.
    Kaplan BC, Dart RG, Moskos M, et al. Ectopic pregnancy: prospective study with improved diagnostic accuracy. Ann Emerg Med. 1996;28:10–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Wang R, Reynolds TA, West HH, et al. Use of a β-hCG discriminatory zone with bedside pelvic ultrasonography. Ann Emerg Med. 2011;58:12–20.CrossRefPubMedGoogle Scholar
  12. 12.
    Doubilet PM, Benson CB, Bourne T, et al. Diagnostic criteria for nonviable pregnancy early in the first trimester. N Engl J Med. 2013;369:1443–51.CrossRefPubMedGoogle Scholar
  13. 13.
    Ko JK, Cheung VY. Time to revisit the human chorionic gonadotropin discriminatory level in the management of pregnancy of unknown location. J Ultrasound Med. 2014;33:465–71.CrossRefPubMedGoogle Scholar
  14. 14.
    Hahn SA, Lavonas EJ, Mace SE, et al. Clinical policy: critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy. Ann Emerg Med. 2012;60:381–90.CrossRefPubMedGoogle Scholar
  15. 15.
    Varma R, Gupta J. Tubal ectopic pregnancy. BMJ Clin Evid. 2012;02:1406.Google Scholar
  16. 16.
    Celik H, Tosun M, Isik Y, et al. The role of early determination of beta-human chorionic gonadotropin levels in predicting the success of single-dose methotrexate treatment in ectopic pregnancy. Ginekol Pol. 2016;87:484–7.CrossRefPubMedGoogle Scholar
  17. 17.
    Zee J, Sammel MD, Chung K, et al. Ectopic pregnancy prediction in women with a pregnancy of unknown location: data beyond 48 h are necessary. Hum Reprod. 2014;29:441–7.CrossRefPubMedGoogle Scholar
  18. 18.
    Devoe R, Pratt J. Simultaneous intrauterine and extrauterine pregnancy. Am J Obstet Gynecol. 1948;56:1119–26.CrossRefPubMedGoogle Scholar
  19. 19.
    Reece E, Petrie R, Sirmans M, Finster M, Todd W. Combined intrauterine and extrauterine gestations: a review. Am J Obstet Gynecol. 1983;146:323–30.CrossRefPubMedGoogle Scholar
  20. 20.
    Goldman GA, Fisch B, Ovadia J, Tadir Y. Heterotopic pregnancy after assisted reproductive technologies. Obstet Gynecol Surv. 1992;47:217–21.CrossRefPubMedGoogle Scholar
  21. 21.
    Tal J, Haddad S, Gordon N, Timor-Tritsch I. Heterotopic pregnancy after ovulation induction and assisted reproductive technologies: a literature review from 1971 to 1993. Fertil Steril. 1996;66:1.CrossRefPubMedGoogle Scholar
  22. 22.
    Louis-Sylvestre C, Morice P, Chapron C, Dubuisson JB. Case report: the role of laparoscopy in the diagnosis and management of heterotopic pregnancies. Hum Reprod. 1997;12(5):1100–2.CrossRefPubMedGoogle Scholar
  23. 23.
    Press GM, Martinez A. Heterotopic pregnancy diagnosed by emergency ultrasound. J Emerg Med. 2007;33(1):25–7.CrossRefPubMedGoogle Scholar
  24. 24.
    Li XH, Ouyang Y, Lu GX. Value of transvaginal sonography in diagnosing heterotopic pregnancy after in-vitro fertilization with embryo transfer. Ultrasound Obstet Gynecol. 2013;41:563–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Dart RG. Role of pelvic ultrasonography in evaluation of symptomatic first-trimester pregnancy. Ann Emerg Med. 1999;33:310–20.CrossRefPubMedGoogle Scholar
  26. 26.
    Somers M, Spears M, Maynard A, Syverud S. Ruptured heterotopic pregnancy presenting with relative bradycardia in a woman not receiving reproductive assistance. Ann Emerg Med. 2004;43:382–5.CrossRefPubMedGoogle Scholar
  27. 27.
    Divry V, et al. Case of progressive intrauterine twin pregnancy after surgical treatment of cornual pregnancy. Fertil Steril. 2007;87(1):190.e1–3.CrossRefGoogle Scholar
  28. 28.
    Wang Y, et al. Efficacy of local aspiration in the conservative treatment of live interstitial pregnancy coexisting with live intrauterine pregnancy after in vitro fertilization and embryo transfer. Chin Med J (Engl). 2012;25:1345–8.Google Scholar
  29. 29.
    Everett C. Incidence and outcome of bleeding before the 20th week of pregnancy: prospective study from general practice. BMJ. 1997;315:32–4.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Mohammed F. The outcome of pregnancies in 182 with threatened miscarriage. Arch Gynecol Obstet. 2004;270:86–90.Google Scholar
  31. 31.
    Hsu LYF. Prenatal diagnosis of chromosomal abnormalities through amniocentesis. In: Milunsky A, editor. Genetic disorders and the fetus. 4th ed. Baltimore: The Johns Hopkins University Press; 1998. p. 179.Google Scholar
  32. 32.
    Menasha J. Incidence and spectrum of chromosome abnormalities in spontaneous abortions: new insights from a 12-year study. Genet Med. 2005;7:251–63.CrossRefPubMedGoogle Scholar
  33. 33.
    Nybo Andersen AM, Wohlfahrt J, Christes P, et al. Maternal age and fetal loss: population based register linkage study. BMJ. 2000;320–1708.Google Scholar
  34. 34.
    Blavias M, Sierzenski P, Plecque D, et al. Do emergency physicians save time when locating a live intrauterine pregnancy with bedside ultrasonography? Acad Emerg Med. 2000;9:988.CrossRefGoogle Scholar
  35. 35.
    Adhikari S, Blavias M, Lyon M. Diagnosis and management of ectopic pregnancy using bedside transvaginal ultrasonography in the ED: a 2-year experience. Am J Emerg Med. 2007;6:591–6.CrossRefGoogle Scholar
  36. 36.
    Varner C, Balaban D, McLeod S, et al. Fetal outcomes following emergency department point-of-care ultrasound for vaginal bleeding in early pregnancy. Can Fam Physician. 2016;7:572–8.Google Scholar
  37. 37.
    Chiem AT, Chan CH, Ibrahim DY, et al. Pelvic ultrasonography and length of stay in the ED: an observational study. Am J Emerg Med. 2014;12:1464–9.CrossRefGoogle Scholar
  38. 38.
    Tuuli MG. Perinatal outcomes in women with subchorionic hematoma: a systematic review and meta-analysis. Obstet Gynecol. 2001;117:1205–12.CrossRefGoogle Scholar
  39. 39.
    Glaser AP, Schaeffer AJ. Urinary tract infection and bacteriuria in pregnancy. Urol Clin North Am. 2015;4:547–60.CrossRefGoogle Scholar
  40. 40.
    Society for Assisted Reproductive Technology, American Society for Reproductive Medicine. Assisted reproductive technology in the United States: 2001 results generated from the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology registry. Fertil Steril. 2007;87:1253–66.CrossRefGoogle Scholar
  41. 41.
    Land JA, Evers JL. Risks and complications in assisted reproductive techniques: report of an ESHRE consensus meeting. Hum Reprod. 2003;18:455–7.CrossRefPubMedGoogle Scholar
  42. 42.
    Qin J, Liu X, Sheng X, et al. Assisted reproductive technology and the risk of pregnancy-related complications and adverse pregnancy outcomes in singleton pregnancies: a meta-analysis of cohort studies. Fertil Steril. 2016;105:73–85.CrossRefPubMedGoogle Scholar
  43. 43.
    Luke B, Gopal D, Cabral H, et al. Perinatal outcomes of singleton siblings: the effects of changing maternal fertility status. J Assis Reprod Genet. 2016. [Epub ahead of print]Google Scholar
  44. 44.
    Perkins KM, Boulet SL, Kissin DM, et al. Risk of ectopic pregnancy associated with assisted reproductive technology in the United States, 2001-2011. Obstet Gynecol. 2015;125:70–8.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Bu Z, Xiong Y, Wang K, et al. Risk factors for ectopic pregnancy in assisted reproductive technology: a 6-year, single-center study. Fertil Steril. 2016. [Epub ahead of print]Google Scholar
  46. 46.
    Londra L, Moreau C, Strobino D, et al. Ectopic pregnancy after in vitro fertilization: differences between fresh and frozen-thawed cycles. Fertil Steril. 2015;104:110–8.CrossRefPubMedGoogle Scholar
  47. 47.
    Ohannessian A, Crochet P, Courbiere B, et al. Methotrexate treatment for ectopic pregnancy after assisted reproductive technology: a case-control study. Gynecol Obstet Fertil. 2016;44:341–4.CrossRefPubMedGoogle Scholar
  48. 48.
    Kwik M, Maxwell E. Pathophysiology, treatment and prevention of ovarian hyperstimulation syndrome. Curr Opin Obstet Gynecol. 2016;28:236–41.CrossRefPubMedGoogle Scholar
  49. 49.
    Raziel A, Friedler S, Schachter M, et al. Increased early pregnancy loss in IVF patients with severe ovarian hyperstimulation syndrome. Hum Reprod. 2002;17:107–11.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Department of Emergency MedicineMedStar Washington Hospital Center and MedStar Georgetown UniversityWashington, DCUSA

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