597

Sonographic Differentiation
between Blighted Ovum and
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Early Viable Pregnancy

Keith G. Bernard1 Thirty-five patients referred either for confirmation of pregnancy or because of vaginal
Peter L. Cooperberg1 bleeding associated with early pregnancy were examined sonographically. The sono-
grams were evaluated prospectively to determine whether a blighted ovum or early
missed abortion could be differentiated from an early viable pregnancy lacking fetal
echoes. A well defined trophoblastic reaction, continuous around the gestational sac, is
a very good prognostic
sign for continued viability; a sac greater than 2 cm in diameter
without embryonic echoes is a poor prognostic sign. However, no sonographic features
were found to be reliable in differentiating viable from nonviable pregnancy (presenting
as an empty gestational sac) on a single sonographic examination. The authors rec-
ommend follow-up sonographic evaluation in 10-14 days.

Pregnant patients are often referred for sonographic evaluation of early first-
trimester bleeding, which may be related to a threatened abortion. The major
concern in such cases is whether or not the pregnancy is viable, since this will
affect clinical management. However, before a live embryo is visualized in the
intrauterine gestational sac, it can be difficult to differentiate between a normal
early viable pregnancy and a blighted ovum. As a result, the usual clinical practice
is to exercise caution and repeat the examination after an interval. Since most
investigations of this problem have been done using bistable [1 21 or static gray- ,

scale or linear-array equipment [3], we wished to reassess the usefulness of state-

of-the-art high-resolution neal-time sector scanning equipment in the differentiation
and to determine whether there are any features that would enable the distinction
to be made at the time of the first scan. Thirty-five women were evaluated
sonographically for determination of pregnancy viability. Various sonographic fea-
tunes are discussed with respect to accuracy in predicting pregnancy outcome.

Subjects and Methods

Thirty-five women in their reproductive years were examined sonographically either for
confirmation and dating of pregnancy or because of vaginal associated with a
bleeding
suspected pregnancy. In 22 of these, a second follow-up sonogram was obtained. Only cases
in whom an empty sac was present were included in the study group; if any fetal echoes
were detected, the case was excluded. However, cases were included if there was only a
yolk sac present.
Pelvic scans were performed using commercially available mechanical sector scanners
Received July 3. 1984; accepted after revision with either a 3.5 MHz or a 5.0 MHz transducer. The intrauterine gestational sac of each
October4, 1984.
patient was evaluated for sac size, sac shape, prominence of trophoblastic reaction, and
1 Department of Radiology, University of British
continuity of the trophoblastic reaction around the sac. In the 22 patients who had a second
Columbia and Vancouver General Hospital, 855 W.
follow-up scan, sac growth was also evaluated.
12th Ave. , Vancouver, B.C. V5Z 1 M9, Canada.
Address reprint requests to P. L. Cooperberg. Sac size was determined by averaging the sac’s sagittal diameter, width, and height; sac
growth was calculated by determining the difference in the sac’s average diameter between
AJR 144:597-602, March 1985
0361 -803x/85/1 443-0597 the first and second examinations. Prominence of the trophoblastic reaction was evaluated
C American Roentgen Ray Society subjectively as poor, fair, or good on the basis of the echogenicity and thickness of the
 598 BERNARD AND COOPERBERG AJR:144, March 1985
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Fig. 1 .-Sagittal (A) and transverse (B) real-time sector scans of intrauterine gestational sac containing Fig. 2.-Transverse scan of blighted ovum shows
yolk sac. large gestational sac devoid of fetal echoes.

TABLE 1 : Sonographic Findings in 35 Early Pregnancies anembryonic pregnancy (blighted ovum) and early embryonic
Nonviab Pregnancies demise (early missed abortion). These two types of nonviable
Gestational Sac
Viable (n = 15) pregnancy were differentiated by the presence on absence of
Characteristics
Pregnancies Early a yolk sac indicating the existence of embryonic tissue [4]
(n - ) Ova Embryonic (fig. 1 ). Since patients with fetal body echoes (from either a

Sac size (cm)*

Pointed shape (% of cases)
_________
-i -.-- - 81 ‘ 75 8 living
of earlyon missed
dead fetus)
abortionwere showed
not included
a yolk in sac
the only;
study, there
all cases
were

Sac growth:t four patients in this group. There were 1 6 cases of a blighted
% of cases 100 62.5 5Q ovum in which there was no embryonic tissue or yolk sac.
Rate (cm/day) 0.12 0.025 0.1 1 The sonognaphic findings are summarized in table 1 The .

Trophoblastic reaction:
average diameter of the sac in the nonviable pregnancies
Quality:
Good 67 19 50 (both blighted ovum and early missed abortion) was 1 .8 cm.
Fair 33 44 . . . In the viable pregnancies, it was 1 .3 cm. No sac greaten than
Poor . . . 37 50 2.0 cm in average diameter without fetal parts proved to be
Continuity(% of cases) 87 50 50 a viable pregnancy (fig. 2). Sac shape determination revealed
Both good quality and continuity
67 12 5 50 that 53% of viable pregnancies had a pointed sac as opposed
(% of cases)
. to a round on oval sac, whereas 81 % of the blighted ovum
. Sac size was determined by averaging the sacs sagittal diameter, width, and height;
values given are means.
and 75% of the early embryonic demise cases had a pointed
t Sac growth = difference in sac size between first and second examinations. Values sac.
given are means. On the basis of the echogenicity and thickness of the
trophoblastic ring around the sac, 67% of the viable pnegnan-
cies had a good tnophoblastic reaction (fig. 3A), 33% a fain
trophoblastic ring. Finally, the continuity of the trophoblastic reaction reaction, and none a poor reaction. On the other hand, of the
was assessed according to whether or not the trophoblastic ring blighted-ovum pregnancies, only 19% had a good reaction
surrounding the gestational
sac was interrupted. (fig. 4A), whereas 44% had a fain reaction (fig. 4B) and 37%
These factors were then correlated with the final outcome of the a poor reaction (fig. 4C). The early embryonic demise cases
pregnancy. In 20 patients, the results of scrapings from dilation and were evenly divided between a good (fig. 5) and a poor
curettage were available. The remaining 1 5 patients had a normal reaction.
continuation of pregnancy. Continuity of the tnophoblastic reaction around the gesta-
tional sac was present in 87% of the viable pregnancies. The
other 1 3% of the viable pregnancies had a noncontinuous
Results
ring. In the nonviable pregnancies (both blighted ovum and
Of the 35 women evaluated, 15 proved to have viable early embryonic demise), 50% had a continuous ring and 50%
pregnancies whereas 20 had nonviable pregnancies. The a noncontinuous one (fig. 6).
nonviable pregnancies could be divided into two groups: In combining the last two factors, that is, quality of the
 AJR:144, March 1985 SONOGRAPHY OF BLIGHTED OVUM 599
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1c:; !

.---:

.L...

!c- -- .:
#{149}: _:‘:.:

Fig. 3.-Sagittal scans of three viable pregnancies. A, Gestational sac with good trophoblastic reaction. B and C, Examples of small gestational sac with poorly
defined trophoblastic reaction.

Fig. 4.-Sagittal scans of three blighted ova showing sonographic appearance of good (A), fair (B), and poor (C) trophoblastic reaction.

trophoblastic reaction and continuity of the ring around the day; in the early embryonic demise cases, 500/c showed
gestational sac, it was found that 67% of the viable pregnan- growth at a rate of 0.1 1 cm/day.
cies had both a good reaction and a continuous one, whereas
only 1 2.5% of the blighted-ovum pregnancies and 50% of the
Discussion
early embryonic demise cases had both.
The average daily growth of the gestational sacs was About 1 0%-1 5% of all pregnancies result in clinically ap-
evaluated in 1 2 of 1 5 viable pregnancies and 10 of 20 nonvi- parent abortion [5]; however, this represents only a small part
able pregnancies. Repeat sonograms 7-1 4 days after the of pregnancy failures, since numerous cases of blighted ovum
initial scan allowed the average daily growth to be calculated. go undetected. In 1980, Miller et al. [6], in evaluating postim-
Sac growth occurred in 1 00% of the viable pregnancies at an plantation pregnancy wastage, reported that 43% of pregnan-
average rate of 0.12 cm/day. In the blighted ovum population, cies end in failure. However, only one-fifth of these cases are
growth occurred in 62.5% and at a rate of only 0.025 cm/ clinically recognized as spontaneous abortions. A lange pen-
 600 BERNARD AND COOPERBERG AJA:144, March 1985

Fig. 5.-A, Initial sagittal scan of gestational sac

with good trophoblastic ring in early pregnancy. B,
Transverse scan 7 days later shows dead embryo.
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Fig. 6.-Transverse (A) and sagittal (B) scans of

blighted ovum with noncontinuous trophoblastic
ring.

‘-:-‘

centage of these pregnancy failures are secondary to a chonionic gonadotropin, progesterone, and estradiol) in pa-
blighted ovum. tients with threatened abortion [1 0, 1 1].
The principal abnormality of the early pregnancy failure It was not until the late 1 960s and early 1 970s that sonog-
(blighted ovum) is an abnormal karyotype [5]. In a 1 978 study raphy was technically advanced enough to contribute to the
by Bou#{233}and Bou#{233} [7] of nearly 1 500 abortions, 61 .5% had diagnosis of threatened abortion. Although only static bistable
an abnormal karyotype; the three major abnormalities were equipment was being used at that time, evaluation of the
autosomal trisomy (52%), triploidy (1 9.8%), and monosomy early threatened abortion was being performed. Such features
x (15.3%). as loss of definition of the gestational sac, absence of fetal
The incidence of blighted ovum is high (49%-90%) in echoes, small gestational sac for dates, failure of sac growth,
spontaneous abortions overall [8, 9]. Unfortunately, when and low position of the sac within the uterus, were used in
there is clinical suspicion of an early abortion, often neither the diagnosis of blighted ovum. In the 1 972 study by Donald
the history nor the physical examination is reliable in predicting et al. [1 ] using the above criteria, 57 of 66 patients who
pregnancy outcome. Using clinical and laboratory parameters, aborted were judged to have sonographic evidence of
it is quite difficult to diagnose a viable versus a nonviable blighted ovum. Even though these authors believed sonog-
pregnancy until the later stages of pregnancy. Various opin- naphy to be valuable in the early diagnosis of the blighted
ions exist on the prognostic value of hormone assays (human ovum, serial sonognaphic examinations were considered ad-
 AJR:144, March 1985 SONOGRAPHY OF BLIGHTED OVUM 601

visable in many cases since the individual signs were not In combining the last two factors (that is, prominence and
diagnostic unless several obvious abnormal features were continuity of the trophoblastic reaction), an additional cate-
present. gory was produced that had a higher degree of accuracy in
In another early (1 975) study by Robinson [2] using static predicting pregnancy outcome than either factor alone. Sixty-
bistable equipment, 69 blighted-ovum pregnancies were eval- seven percent of the viable pregnancies had a good ring of
uated sonographically. Since he was unable to see the fetus trophoblast that was also continuous, whereas only 12.5%
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in detail and the decidual reaction, Robinson used size alone of the blighted-ovum cases had a good continuoup ring; two
as his criterion. He chose a sac volume of 2.5 ml, without (50%) of four early embryonic demise cases had a similar
evidence of fetal echoes, to make a definitive diagnosis of finding. These results may be compared with a study of 66
blighted ovum at the first sonographic examination. If the sac pathologically proven cases of blighted ova evaluated in 1972
was less than 2.5 ml in volume, but failed to increase by at by Donald et al. [1] using bistable static technique, in which
least 75% in 1 week, this was also considered diagnostic of 35% of the blighted pregnancies had a “poor ring.”
a blighted ovum. Finally, we found that absence of sac growth over a 7- to
Our results suggest that one cannot predict pregnancy 1 4-day period is a good predictor of nonviability. All viable
viability on the basis of a single measurement of sac size. pregnancies experienced sac growth, whereas nearly 40% of
Although the average sac diameter for the viable pregnancies the blighted-ovum and 50% of the early embryonic demise
(1 .3 cm) was 0.5 cm smaller than that of the nonviable cases showed no growth. The average sac growth rate of
pregnancies (1 .8 cm), there was too much overlap in the sac the viable pregnancies was 0.1 2 cm/day, whereas the aver-
size between the two groups to allow accurate differentiation age sac growth rate for the blighted ova was only 0.025 cm/
(three of the 1 5 viable pregnancies had an average gesta- day, a substantial growth rate difference between these two
tional-sac diameter of 1 .8 cm or greater). We did not, how- groups. The average sac growth rate of the early embryonic
ever, find any viable pregnancy with an empty gestational sac demise cases (0.1 1 cm/day) was close to that of the viable
greater than 2.0 cm in diameter, therefore, the presence of a pregnancies.
gestational sac greaten than 2.0 cm average diameter without Obviously, the clinical situation plays an important role in
embryonic tissue is highly suspicious for a nonviable preg- the diagnosis. If clinical signs such as pain, cramping, and
nancy. bleeding strongly suggest that the pregnancy is nonviable,
Sac shape has been used by some to predict pregnancy the absence of a normal fetus on sonognaphy may be suffi-
viability, with angular irregularities considered a reliable mdi- cient confirmation. This is especially true if the urine preg-
caton of abnormalities in the primary sac [4]. We found that nancy test is positive about 2 weeks before the sonographic
although a pointed sac was present in 81 % of blighted-ovum study, indicating that the pregnancy should be at least 8
pregnancies and 75% of the early embryonic demise cases, weeks along at the time of the examination. At this stage, a
53% of the viable pregnancies also had a sac that was pointed definite fetus with a definite heartbeat should be seen if the
to some degree. So even though a pointed sac is more pregnancy is viable. If the clinical findings are not specific,
common in a nonviable pregnancy (with the more irregularly however, we conclude that a single sonogram of an early
shaped sacs associated with a higher likelihood of nonviabil- intrauterine pregnancy showing an empty gestational sac is
ity), the presence of a pointed sac was not an accurate not in itself a reliable indicator of whether or not the pregnancy
predictor in ruling out a viable pregnancy. is viable. If the sac is larger than 2 cm in average diameter
The presence of a good versus a poor trophoblastic neac- and lacking in fetal echoes, it is highly suspicious for nonvia-
tion surrounding the gestational sac was a fain predictor in bility. All other cases require a second examination in 7-14
differentiating a live pregnancy from a blighted ovum, since days to confirm nonviability before definite therapy is under-
67% of the viable pregnancies had a good reaction and none taken.
had a poor reaction. Only 1 9% of the blighted-ovum pregnan-
cies had a good reaction, whereas 37% had a poor reaction. ACKNOWLEDGMENTS
However, because of the small degree of overlap in the good
We thank E. A. (Teddy) Lyons for manuscript review and Betty
and poor trophoblastic categories and the large overlap in the
Fowler for secretarial assistance.
fair trophoblastic category (33% of the viable and 44% of the
blighted ova), the prominence of the trophoblastic reaction
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