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Chapter 1

Failed IUP: Then What?

Ben Shepherd, MD and Rob Orman, MD
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Ben Shepherd, double trained in OB/Gyn and EM breaks down a rational approach to managing patients with failed IUP.

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scott w. -


Great piece...I have always liked the pieces when you have someone who has specialty training in another field talk about a topic.

I do have a question though...I have never been able to define this..what is the definition of an open os in a first trimester pregnancy? The definition of inevitable abortion relies on open os and I am not sure if there is a certain diameter that defines this? Is it just fingertip?


Rob O., MD -

Hey Scott! Here is the answer from Ben Shepherd....

Great Question.

The INTERNAL os is the key here. A lot of women, particularly after a prior vaginal delivery (or prior cervical dilatation if they had a caesarean in late labour) will have an open external os (often called a 'multip' os - referring to multiparous women). All cervical dilatation (or open v closed assessment) refers to the internal os - so make sure that is open if you're gonna call it. Admitting a finger in the setting of early pregnancy bleeding is sufficient to call it open.

Secondly, I'm not even sure the entity of inevitable miscarriage is of any importance in 2020. It was derived prior to easily accessible formal or point of care Ultrasound. Historically it was aiming to find women who hadn't yet, but were likely to progress to miscarriage on clinical grounds. Nowadays ultrasound will tell us whether the pregnancy is intrauterine, and then if it is viable or not. The presence of bleeding / products will tell us if this is a 'missed' or íncomplete' miscarriage.

I guess a viable IUP in the setting of PV bleeding and an open cervical os is quite concerning and it would join the group of viable IUPs with poor prognosis (continued heavy bleeding, FHR < 90 etc). I personally find I no longer have a use for "inevitable miscarriage".

Reuben S. -

This guy is so good. We should stop teaching inevitable, and then the os open/closed question becomes unimportant and we can stop it with the nearly almost always wrongly assessed open/closed os.

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2.25 AMA PRA Category 1 Credits™ certified by Hippo Education (2020)