First Trimester Complications

Fetal Biometry WorkshopDay 1

Objectives

Review presentation , consequences & sonographic findings of ectopic pregnancyDiscuss different types of abortionDefine Blighted OvumReview different types of molar pregnancyIdentify coexisting maternal pelvic masses

Tubal Implantation

Abnormal tubesCongenitalPID***Tubal Surgery

Normal tubesTransmigration of ovumEmbryonic abnormalitiesHormonal imbalancePelvic massesIUDReduced tubal motility

Tubal Implantation

Hormonal Imbalance

EstrogenProgesterone

Tubal Implantation

MechanicalDevelopmental anomaliesInfectious damageTubal surgery

Cervical Implantation

Below level of internal osEndometrium unsuitable

EndometritisIUDRapid transit

Interstitial Implantation

Abdominal Implantation

PrimaryNormal tubes & ovaries

SecondaryTubal abortion with extension into peritoneal surface

Ovarian Implantation

Rare <0.52%Gestational sac occupy ovary position Gestational sac connected to uterus by uteroovarian ligamentOvarian tissue in wall of sacFailure of ovum to leave follicleTubal abortion implants on ovarian surface

Clinical Presentation

Vaginal spotting or bleedingAbdominal painAmenorrheaAdnexal tendernessPalpable adnexal mass+ Pregnancy test

hCGLower levels in ectopicRapid decrease

Hydatidiform moleNonviable pregnancy

Serum amylaseRuptured tubal pregnancy

Sonographic Protocol

Normal uterine pregnancy

GS – 4 to 5 weeks after LMP

Uterine Image with Ectopic

Decidual cyst 3 mm cyst (arrow) is identified within the decidua.

Cyst is not an intradecidual gestational sac

Peripherally located within the decidua Does not abut the endometrial canal

Coronal View Right Adnexa

Fallopian tube filled with fluid [blood]Trophoblastic ring (arrow) Echo-free fluid surrounds the tube Doppler

high-velocity low-resistance flow

Sonographic ProtocolUnruptured tubal pregnancy

Salpingotomy

Sonographic ProtocolRuptured tubal pregnancy

Sonographic Protocol

Chronic tubal pregnancy Blood + trophoblastic tissue + disrupted tubal tissue + inflammatory response = pelvic hematoceleIndefinite uterus sign – echogenicity similar to uterusMimics endometriosis and PID

Treatment Options

Surgical intervention Laparoscopy or laparotomySalpinectomyHysterectomyD & C

Non-Surgical interventionAdminister MethotrexateCuldocentesis

Treatment Options

Wait & See ApproachDecreasing hCGNo evidence of intrauterine pregnancyNo fetal heartbeatNo sign of bleeding or tubal rupture

Case StudySagittal transvaginal uterine scan

Case Study Transvaginal scan of the right adnexa

Case StudySagittal view of the right adnexa

Case StudyPower Doppler Right Adnexa

Sonographic Differential

Ectopic Location Differential Diagnosis

Tubal ·         Corpus Luteum cyst·         Adnexal mass·         Ahesed bowel·         Acute appendicitis

Ovarian ·         Tubal ectopic·         Bowel [mass-like]·         Hemorrhagic corpus luteum cyst

Abdominal ·         Severely retroflexed uterus·         Bicornuate uterus

Cervical ·         Impending or incomplete abortion·         Degenerating cervical myoma

Chronic ectopic ·         Pelvic inflammatory disease·         Degenerating myoma·         Endometrioma

Interstitial ·         Myoma·         Bicornuate uterus with pregnancy in horn

Abortion (AB)

Interruption of a pregnancyCauses of AB

InducedSpontaneous

Fetal malformationHormone inadequaciesDefective implantationPlacental maldevelopment or separationRh incompatibilitySystemic infection or toxic agentsMaternal traumaMultiple fibroids/submucosal fibroids

Varieties of AB

Spontaneous ABInevitable ABIncomplete ABComplete ABMissed ABSeptic AB

Spontaneous AB

Abortion before 20 weeks gestation Mostly 5th-12th week Vaginal bleeding

Possible no knowledge of pregnancy

May require D&CType

Threatened AB (clinical diagnosis)Vaginal bleeding in early pregMild crampingPossible visible fetusSac in Isthmus of uterusNot dilatation of cervix50% go on to abort

US findings of SAB

Check sac placementIt should be high for normal preg.

Check sac appearanceIs there a double decidual signUterine sizeMost likely there will be a recheck for any changes

Sono Findings - Poor Outcome

Abnormal Hi/Low hCGLarge subchorionic hematomaHeart rate <80 bpmAbnormal sac size/ embryo sizeSac size too small or too big compared to embryoDistorted sac shapeLow position in endometrial cavityBeware if heart beat seen, then this takes precedence to show live IUP over all the above

D&C

Dilatation and CurettageScraping of the endometriumCan leave scarring

Inevitable AB – In Progress

Incomplete AB

Partial evacuation of fetus and placentaSome retained products, Fetus expelledPlacenta usually remains

Signs & SymptomsUsually painBleeding/clottingD & C needed

Sonographic findingsStill increase in uterine sizeThick heterogeneous and echogenic endometrium w/hypervascularity

Complete AB

The entire pregnancy is totally expelled

Sonographic findingsIncrease in uterine sizeNo gestational sac or fetus seenDecidual reaction might still be visible

Missed AB

Sonographic findingsFetus doesn’t occupy whole uterusFetus may be macerated

Shapeless, ill defined echoes

Poor imagingNo amniotic fluid to delineate structures

Fetal demiseFetal skull plates may overlap – “spaulding sign”

Uterus small for date (SGA)

No fetal heart motion

Retention of dead pregnancy for at least 2 months

Fetus and placenta retained before 18-20 wks

Placenta remains attached

Amniotic fluid reabsorbed

Septic AB

Infected dead fetusMay show gas formationGas in uterus from bacteriaHow does gas show up on US?

Abortions

Threatened AB due to early abruption of placenta, can correct itselfspontaneous

Blighted Ovum

Anembryonic pregnancySac with no fetal polePositive beta hCGDifferent growth rates of GS

Small GS and large uterusIncreasing GS size and normal uterus

Blighted Ovum

Intrauterine sac with no fetal poleIrregular borders or ill definedLike a spontaneous or incomplete ABVaginal bleedingCheck sac size with LMP

Hemorrhage

Innocent bleedSmall period 1 month s/p conception

Implantation bleedAbortionsChorioamniotic elevations

Extrachorionic bleedUsually not serious concern

Subchorionic Blood accumulation between chorion & decidua vera

Subchorionic hematoma/hemorrhage

Subchorionic hematoma/hemorrhage

Pseudogestational Sac

Free fluid within the endometriumCan simulate an IUP early onTypically the sac size is irregular and there is not a pronounced double decidual sign

+/- slight echogenicity around the pseudo sacNo yolk sac and or fetal pole are signs of a pseudo sac

Other considerations for pelvic mass

Persistent corpus luteumPID/TOAAppendiceal abscessEndometriomaDermoidHydrosalpinxHemorrhagic or ruptured ovarian cystFluid filled bowelIn these cases what is an important ? To ask

Molar Pregnancy gestational trophoblastic disease

Increase in HCG x 10 for current age of pregnancyRemains elevated after 60 daysPrevious moleAssociated with

missed AB or blighted ovumTheca lutein cysts

Occur w/ 20-50% of molar pregnancyForm in response to increase HCGUsually large and multiloculatedBilateralResolve after mole removed

Molar Classification

Hydatidiform mole (complete)Partial moleCoexisting fetus and moleLocally invasive moleMetastatic choriocarcinoma

Hydatidiform Mole

Hydatidiform Mole

Partial Mole

Coexisting fetus and molar preg

By def.- dizygotic twin gestationMole complete or partialFetusCan become invasive

Locally Invasive Mole

Aka- chorioadenoma destruensInvasive but does not metastasizeBy def.- chorionic villi penetrate myometriumCan have invasion of bladder wall with hemorrhage of local vesselsExtensive proliferationVilli pattern preserved

Metastatic Mole Choriocarcinoma

Molar Pregnancy Symptoms

Vaginal bleeding may be present with painIncrease hCGLGA- rapid growthHyperemesis

This is the most common of all the symptoms

Signs of preeclampsia (HTN, proteinuria, edema)Theca lutein cystsVessicles passed vaginally (not typical)

Leiomyomas / fibroids

Common pelvic tumor (esp. >35 year old)Fibromuscular, most are benignEtiology

Ovarian hormone imbalanceFeed on estrogen and get larger

CharacteristicsVariable sizeVascular and can degenerateCan have central cystic necrosisCalcify over time Very dense

Leiomyomas

Presentation during pregnancy1Tri. Can cause SAB3Tri. Can interfere with delivery or precipitate preterm labor

SymptomsAsymptomaticIncrease sensation to urinatePainProfuse/prolonged bleedingEnlarged and irregular uterus

Sonographic findingsDepends on location, changes and internal characteristicsHypoechoic and heterogeneousRing of blood flowAttenuate soundCan look like molar pregnancy

Leiomyomas / fibroids

LeiomyomasLeiomyomas / fibroids

Cystic Hygroma

Cystic lymphangiomaAnomalous development in communication between venous system and lymphaticMostly benignLooks similar to meningomyelocele but no bony defectSonographic findings

Multi septated cystic massEvaluate spine for defect and herniating mass

Nuchal Translucency

11-13 weeks gestationDon’t get this mixed up with nuchal fold done later in pregnancy

Watch out for amnionShould be less than 3mmBounce

Fetal Demise

Review …

A patient presents for ultrasound at 7 weeks gestation with bleeding and acute pain. The patient also reveals a history of endometriosis. The sonographer identifies a uterus without evidence of an IUP. This would suggest?

Ectopic pregnancyThreatened abortionMissed abortionIncomplete abortionSpontaneous abortion

Review …

What is the most common patient presentation of an ectopic pregnancy?What are the risk factors for an ectopic pregnancy?What are diagnostic criteria [sonographic & lab] for an ectopic pregnancy?