Following these publications, the Royal College of Obstetricians and Gynaecologists immediately changed its guidance to one based on an empty gestational sac of mean gestational sac diameter 25 mm or embryo with a crown rump length 7 mm and no heartbeat.7 In December 2012 the UK National Institute for Health and Care Excellence adopted the recommendations of the Royal College of Obstetricians and Gynaecologists.8 The American College of Radiology guidance then also changed in 2013 and adopted the same criteria as the Royal College of Obstetricians and Gynaecologists to define miscarriage.9 As part of its guideline pandora jewellery, NICE stated that for empty gestational sacs and embryos below the cut off values, if the sac was empty or no embryo heartbeat was visible on an ultrasound scan after 7 10 days, these were definitive criteria for miscarriage. NICE reported no consensus on timing and frequency of repeat ultrasound scans for initially inconclusive scans and identified this as a research priority.8 Later in 2013 a review in the New England Journal of Medicine based on a consensus meeting of the US Society of Radiologists in Ultrasound highlighted the risks of incorrectly diagnosing early pregnancy failure and recommended criteria to diagnose miscarriage.10 This narrative review stated that the absence of an embryo with a heartbeat 14 days after a scan showing an empty gestational sac or absence of an embryo heartbeat 11 days after a scan showing a gestational sac and yolk sac were both categorically a miscarriage. These further recommendations were based on expert opinion but were not evidence based..
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