Confused about gestation and location of pregnancy

Question: I am very grateful to Pregnancy Bliss for educating me on the state of my pregnacy related complications. God bless you for the good job!!
Just a little reminder; i reported abdominal pains and brownish discharge two weeks ago. Pregnancy Bliss advised i carry out a Beta HCG test which i did. The results indicated i was 4 to 5 weeks pregnant and there was a mass in my left ovary. The right ovary was normal As explained in an earlier read literature, the fetus will be invisible at this stage so the scan result indicated an empty uterus. My gynea put me on Primolut and recommended bed rest, which improved my condition. I stopped spotting and when i reported back to the gynea on the 5/04/2011, he recommended a repeat of Beta HCG and abdominal scan scheduled for 15/04/2011.

Now on the 9th April 2011, i woke from bed with severe pains in the region of the joint between my inner left thigh and abdomen. It became so severe like menstrual crubs and started bleeding too; i called my gynea who requested i report immediately at the hospital. A scan was carried out immediately (and by my LMP (21/02/2011) I was 7 weeks pregnant). There was no gestational sac. The gynea confirmed an ectopic pregnancy and gave me an antibiotic -Amoksiklav- and asked that i report back on the 13th April 2011.
On the eve of 9/04/2011, i miscarried. I saw my baby. I was able to see its eyes and nose. It looked like a large tadpole.

My question for today is that with the above history, where exactly was the pregnancy sited.

Secondly, now that the fetus has been aborted, are there any remains? I did not discharge any thing like a sac with fluid and is there any such thing?

Thirdly, my gynea has recommended a D&C. He explained that due to the ectopic pregnancy, the uterus will need "washing". My question is that once the scan showed that there was no activity in the uterus, is there really the need for the D&C? Alternatively, can the D&C be carried out at the region where the fetus was implanted? MP (Ghana)

Answer: I’m afraid the information does not quite add up. Please bear with me and I will explain why. What is now beyond doubt is that you were indeed pregnant. What is far from clear is what gestation you were and indeed where the pregnancy was located. At 7 weeks, a pregnancy inside the uterus should always be seen using an ultrasound scan. That is, unless the operator is not competent, the machine is of very poor quality or the woman is extremely obese (or a combination of these). You said when you miscarried you saw the baby. Your description is very convincing so I have no reason to doubt you. However, that suggests the pregnancy was more advanced than your dates suggest. You know, at 7 weeks, the fetus is really tiny, averaging about 9 -10 mm (that’s just a centimetre at most. You can imagine how tiny that is!) When somebody describes what they have seen as “like a large tadpole”, it makes me think this pregnancy was clearly much more advanced than the said 7 weeks. Just to give you a full picture of the size of the fetus at various stages of the first trimester, I am including a table of the average size by weeks up to 14 weeks (below). The abbreviation CRL stands for Crown Rump Length, which is how the length of the fetus is measured. Now to the other issues.

As I said before, I think what you have described is a classic spontaneous miscarriage, unless there is ongoing active bleeding, there is absolutely no need to have a D&C. Standard D&Cs after a miscarriage is a practice that was abandoned more than 30 years ago. It serves no useful purpose and could do harm. The fact that you did not see any gestational sac or fluid should not surprise you. You are really not expected to see these in most cases of early pregnancy miscarriage. The membranes (of the sac) will usually rupture in the miscarriage process and the little amount of fluid there is at this stage will just mix with blood. Was this an ectopic? Most probably not. The products of conception you saw were definitely coming from the womb cavity. In other words, a normal pregnancy. There is a type of ectopic called ‘heterotopic’ whereby you, in effect, have twins; one in the womb and the other one outside (ectopic) usually in the fallopian tube. This is rare, with an incidence of 1 in every 30,000 pregnancies. Unless you had this, yours could not have been an ectopic. As I said, this is rare and in the absence of symptoms, it can be discounted. I am puzzled and, frankly, disappointed by how your doctor proposed to manage what he/she thought was an ectopic. Ectopic pregnancy is always an emergency and when strongly suspected, the woman should be offered surgery immediately. Remember, an ectopic has to be removed abdominally. It cannot be accessed vaginally. There is more information about ectopic pregnancy here: I will summarise by saying that you most probably have had a complete miscarriage of a normally located pregnancy of uncertain gestation. The fetal size (CRL) table is below. Best wishes.

Scan does not show the pregnancy

Question: Is it possible for me to have a blind pregnancy even though the blood test and pregnancy test are both positive but the ultrasound doesn't show any sign of a baby or is it simply too early to be seen.What does it mean? Please help. L (Australia)

Answer: There is no such thing as a ‘blind pregnancy’. An ultrasound scan should show a pregnancy at 6 weeks gestation or above as long as it is located inside the womb cavity. If you have a definite positive pregnancy test and your gestation is over 6 weeks, the possibility of an ectopic pregnancy needs to be looked at and actively investigated. If you are uncertain about the dates and there is a possibility that the pregnancy is significantly less than 6 weeks, that may be the reason why nothing is seen on a scan.

Weeks

CRL (mm)

4.9

9.2

CRL table