This is one of the most exciting and anxiety provoking moments in a woman’s life.
Whether you were trying, timing your ovulation, it’s unplanned, whatever the circumstances may be surrounding it, a positive pregnancy test brings on a wave of emotions. What can be really frustrating though, is not knowing what this means. As an obstetrician, it can be extremely challenging to explain to women that we just have to wait and see. I want to be able to tell you everything is fine, the gender, what Ivy League school your fetus will attend, and how many grandkids to expect. Obviously this doesn’t happen during your pregnancy confirmation appointment. I want to explain some of the things we worry about in an early pregnancy, and why it can be so hard to know exactly what is going on for a while.

Early pregnancy changes drastically from week to week. At 5 weeks, there’s a small gestational sac. At 6 weeks you can see a small fetal pole in that gestational sac. Between 6-7 weeks a heart beat develops. After about 8 weeks it should be fairly simple to see a fetus with a heartbeat, and from 8-14 weeks, the gestational age of the pregnancy is measured using the crown-rump length (top of the head to the lowest part of the spine). This measurement can be +/- 5 days from the dates given to you by your physician and still be considered accurate and within range.

Because things change and develop relatively quickly in a short period of time, we are very dependent on an accurate last menstrual period. So for the woman with irregular cycles, or cycles that don’t subscribe to the 28 day rule, we have no basis for dating. This is challenging in the first trimester. I have done ultrasounds on women that were supposed to be 8-9 weeks along, and see nothing but a small gestational sac. Now what? Now I have to tell the patient, her husband, and whatever other family she has with her that I can’t give them the perfect social media worthy profile picture and they should cancel the announcement they had planned for that weekend. I also can’t reassure them that this is a normal pregnancy. Was she, in fact, close to 8 weeks and nothing ever developed? Did she just ovulate later than normal and we are all getting anxious because I did the ultrasound early? Can be very anxiety provoking for everyone. As a provider, I hate not being able to give people answers. When this situation arises, another test we can look at it the HCG value (or the pregnancy hormone). If a woman’s HCG level is decreasing in a period of 48 hours, this is not a normal pregnancy. If the value is increasing, it can either be a normal pregnancy, or a miscarriage that didn’t “get the memo” yet. When this happens I recommend repeating the ultrasound in 5-7 days to check if there is any progress.

Let’s discuss some of the terms you may hear early in pregnancy when we don’t find what we expect.

1. Miscarriage (abbreviated AB which stands for abortion, whether induced or spontaneous): essentially any pregnancy before 20 weeks gestation that does not result in a baby being born. This is a blanket term. The test was positive, but either no fetus developed, the fetus stopped growing, something basically halted the pregnancy from continuing. The majority of miscarriages can be attributed to a genetic mishap while the pregnancy is forming.
2. Blighted ovum: If an ultrasound is done, and then repeated in 2-3 weeks and no fetal pole is ever seen, this is a blighted ovum. The egg and sperm fertilized and made their way into the uterus, but nothing grew in side. On ultrasound it looks like a thin walled cyst in the uterus.
3. Threatened AB: This is when a woman has symptoms that could result in pregnancy, but no ultrasound or lab findings consistent with that. She may come in with bleeding, or cramping but still have a normal fetal pole and heart beat on ultrasound. We usually counsel these women to take it easy, avoid sex, tampons, pelvic exams and monitor their symptoms very closely.
4. Incomplete AB: If, unfortunately, a woman comes in with bleeding and cramping, and there is no evidence of a fetal heartbeat, and her cervix is already open, this is an incomplete AB. The process has already naturally started to take place in the body. These women have the option to undergo a surgical procedure (D&C) to clean the uterus out, or monitor the bleeding and symptoms at home.
5. Ectopic Pregnancy: This is a scary one. The fertilized embryo doesn’t make the total journey to the uterus, and gets stuck in the tube. It decides to stay, implant itself into the tube, and start growing. This can be extremely dangerous because the tube has the approximate diameter of a pinky finger, and can rupture once the pregnancy grows too large (usually around 6-8 weeks). This is not a normal pregnancy and needs to be terminated with either medication or surgery as soon as possible. Delay of treatment can result in dangerous bleeding in the abdomen and even death.

Going to the doctor and not getting the answers you’re hoping for can be extremely hard. Miscarriage is extremely common, 33% of pregnancies do end in miscarriage.  It is often a test of patience to have to wait 2-4 weeks to figure out what is going on. Especially difficult is that discussing miscarriage isn’t very common and women often feel isolated in their pain. Although it is not very consoling, the majority of women do go on to have normal pregnancies after a loss. Remember to follow up with your physician if your pregnancy test is positive, and you have any symptoms of heavy bleeding, intense pain or cramping, or severe nausea.

Check back in the next few days for some tips and tricks on surviving the first trimester!

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