Ultrasound Obstet Gynecol 2002; 20: 267– 269
Gestational sac diameter in very early pregnancy as
Blackwell Science, Ltd
a predictor of fetal outcome
J. S. OH*, G. WRIGHT† and C. B. COULAM†
*Department of Obstetrics and Gynecology, Mercy Hospital and Medical Center and †The Sher Institute for Reproductive Medicine, Chicago,
Illinois, USA
KEYWORDS: Early pregnancy, Gestational sac size, Miscarriage, Pregnancy outcome, Ultrasound
ABSTRACT
Objective To determine whether transvaginal sonographic
measurement of gestational sac diameter in pregnancies
28–42 days from the last menstrual period can predict
whether a pregnancy results in a normal term birth or a
spontaneous miscarriage.
Design Gestational sac diameter was measured during the
4th and 5th weeks of gestation from the last menstrual period
in 67 women who had a total of 102 ultrasound scans. These
pregnancies were followed until one of two outcomes occurred:
term gestation (n = 32) or spontaneous miscarriage (n = 35).
Gestational sac diameter as a function of gestational age was
compared in each of the groups.
Results The mean diameter of the gestational sac at 28–
35 days from the last menstrual period among normal
pregnancies did not differ significantly from that in those that
subsequently miscarried (2.6 mm vs. 2.7 mm; P = 1.00). In
pregnancies 36–42 days from the last menstrual period, the
mean sac diameter was significantly different between the
two groups (normal group, mean sac diameter, 8.2 mm and
miscarriage group, mean sac diameter, 4.5 mm; P < 0.001).
Conclusion There is no difference in gestational sac dia-
meter at 28–35 days from the last menstrual period in nor-
mal and abnormal pregnancies. However, smaller than
expected sac diameter in pregnancies 36–42 days from the last
menstrual period is predictive of spontaneous miscarriage.
INTRODUCTION
Since the advent of the transvaginal approach in early
pregnancy ultrasound, the growth and development of
first-trimester pregnancies have been elucidated in increas-
ing detail1–5. Expected gestational sac diameter has been
described in first-trimester gestations from 35 days from the
last menstrual period (LMP) onwards3–5. In addition, a number of
studies have shown that a smaller than expected gestational sac
Correspondence: Dr J. Oh, 2479 Chestnut Avenue, Glenview, IL 60025, USA (e-mail: jsk901@yahoo.com)
Accepted 7-6-02
ORIGINAL PAPER
diameter predicts impending loss in pregnancies of 5.5 weeks’
gestation and above6–8. Most of the latter studies have exam-
ined later first-trimester pregnancies, i.e. > 37 days from
LMP. Little is known of the value of such measurements
in pregnancies < 37 days based on LMP. To determine the
predictive value of gestational sac diameter in very early preg-
nancy, the transvaginal sonographic findings of gestations
at 28–42 days were compared between pregnancies that
resulted in a normal outcome and those that resulted in a
spontaneous miscarriage.
MATERIALS AND METHODS
The study population consisted of infertility patients who
underwent transvaginal ultrasound examination of pregnan-
cies at 28–42 days from LMP. In this retrospective case-
controlled study, women were selected based on pregnancy
outcome. Abnormal outcomes were spontaneous miscarriages
occurring during the first trimester. Normal outcomes were
term deliveries determined when the patients notified the
office of the birth. All of the ultrasound scans of pregnancies
with normal outcomes were collected as the control group.
A similar number of ultrasound scans of women who
eventually had miscarriages, scanned during the same time
period, was selected as the abnormal-outcome group. When
available, follow-up scans from the same pregnancies were
included in each group. The women had either spontaneously
ovulating cycles with regular menstrual cycles and with well
documented LMPs, or had ovarian stimulation cycles for in-
vitro fertilization. Only singleton pregnancies were included.
The gestational ages of spontaneously conceived pregnancies
were calculated from the onset of the LMP. The day of
embryo transfer was used to calculate the gestational age of
pregnancies in women undergoing assisted reproduction.
Two experienced sonographers performed all scans using
the Acuson Sequoia (Acuson Computer Imaging, Mountain
View, CA, USA) with a 7.5–10-MHz transvaginal transducer.
All follow-up scans were performed by the same sonographer.
Gestational sacs were measured in longitudinal and transverse
267
Gestational sac diameter and fetal outcome
Figure 1 Mean gestational sac diameter at 28–35 days from the last
menstrual period in pregnancies with a normal term outcome (䉬) and
those ending in a spontaneous miscarriage (䊏). Data consist of 67 scans
from 67 women.
views and their diameters were averaged. Whenever possible,
additional structures such as the embryonic pole length,
embryonic heart rate, and yolk-sac diameter were also meas-
ured. Because the gestational sac is the only structure reliably
seen in all pregnancies from 28 to 42 days’ gestational age,
this measurement was selected as the point of comparison
among all scans.
The gestational sac diameter of the different outcome groups
was compared using the Mann–Whitney U-test and the Kruskal–
Wallis test. A difference of P < 0.05 was deemed significant.
RESULTS
Sixty-seven women underwent 102 transvaginal ultrasound
examinations from 28 to 42 days from LMP. Thirty-two
women had normal outcomes, yielding 46 scans. Thirty-five
women with pregnancies ultimately ending in spontaneous
miscarriage had 56 scans. Twenty-three of those pregnancies
occurred in spontaneously ovulating women, and the
remainder occurred in patients who underwent ovulation
stimulation by hormonal methods.
Between 28 and 35 days from LMP, the mean gestational
sac diameter did not differ significantly within or between the
two different outcome groups. The mean sac diameter in
normal pregnancies was 2.6 mm, and that in pregnancies
ending in spontaneous miscarriage was 2.7 mm (P = 1.00)
(Figure 1). The mean gestational sac diameter did differ
significantly from 36 to 42 days from LMP between the
abnormal outcome and normal outcome groups (Figure 2).
The mean sac diameter in normal pregnancies was 8.2 mm,
while that in abnormal pregnancies was 4.5 mm (P < 0.001). All
ultrasound examinations performed between 28 and 42 days
from LMP were able to identify a gestational sac. In preg-
nancies 36–42 days from LMP, a gestational sac diameter
of < 6.5 mm was able to predict an abnormal outcome with
a sensitivity of 89.3%, a specificity of 63.2%, a positive pre-
dictive value of 78.1% and a negative predictive value of 80.0%.
DISCUSSION
This study demonstrates that gestational sac diameter does
not differ significantly between 28 and 35 days from LMP
268
Oh et al.
Figure 2 Mean gestational sac diameter at 28– 42 days from the last
menstrual period in pregnancies with a normal term outcome (䉬)and
those ending in a spontaneous miscarriage (䊏). Data consist of 102 scans
from 67 women.
(4–5 weeks’ gestation) nor between successful and unsuc-
cessful pregnancies at 4–5 weeks’ gestation. Pregnancies that
implant apparently start from the same baseline of growth.
When the gestational sac diameters from these pregnancies
were followed for another week, those pregnancies destined
to miscarry fell off this ‘growth curve’ after 35 days from
LMP when the gestational sac reached a diameter of > 3 –4 mm
(Figure 2). This observation is consistent with studies of
neoplastic cells.
Neoplastic tumors can grow to a size of approximately
3 mm nourished by diffusion. However, to exceed this
size, the cells must recruit host blood vessels. The cells at the
center of the neoplasms that survive by diffusion alone are
nutritionally compromised9. Thus, it would be expected
that actively dividing and migrating cells at the core of the
embryonic implantation are likely to be compromised at
3 mm or around 5 weeks’ gestation if no vascularization of
the placenta occurs. If vascularization were impaired, it
would be expected that growth of the conceptus would
continue at a restricted rate (as shown in Figure 2).
Vascularization of the placenta involves complex inter-
actions between cytokines, growth factors and transcription
factors expressed at the site of implantation10. Thus, the
etiologies of miscarriage resulting from impairment of
vascularization of the placenta can be multiple. The most
frequent cause of miscarriage is chromosomal abnormality of
the conceptus11. Poor vascularization of the placenta has also
been documented in chromosomally abnormal pregnancies
with findings of decreased number of capillaries per villus
cross-section12,13.
This study extends the utilization of ultrasound to the
investigation of very early pregnancy by examining pregnancies
at a point when most gestations do not even have a visible
embryonic pole or an identifiable heart rate, but only a gesta-
tional sac is visible. While measurement of the intrauterine
sac prior to 5 weeks of gestation did not prove to be useful
in predicting outcome of the pregnancy as has been previously
reported for gestational sacs after 5 weeks1–9, it provides
potential insights into the role of blood flow among some
pregnancy losses. It is hoped that these insights might suggest
Ultrasound in Obstetrics and Gynecology
Gestational sac diameter and fetal outcome
approaches for future research investigating early pregnancy
losses.
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