Presentation on theme: "Carlos M. Fernandez, M.D Department of Obstetrics and Gynecology"— Presentation transcript:
11st TRIMESTER PREGNANCY FAILURE Shortened to emphasize medical student curriculum requirements Carlos M. Fernandez, M.DDepartment of Obstetrics and GynecologyAdvocate Illinois Masonic and Medical Center
3Diagnosis of IUP “Double decidual sign” at 4½ to 5 wks Gestational sac + yolk sac at 5 wks (a definitive sign of IUP)GS + yolk sac + embryo at 5½ to 6 wksCRL >5 mm – fetal cardiac activity presentSeeber BE and Barnhart KT. Obstet Gynecol 2006;107:
4Tips for Students Gestational age IUP=intrauterine pregnancy Could include a live intrauterine pregnancy, a threatened abortion, an inevitable abortion, an incomplete abortion, or a missed abortionDoes not include ectopic pregnancy, completed miscarriage, or a molar pregnancyGestational ageThe age of the pregnancy in weeks since the last menstrual periodAbout 2 weeks longer than the embryonic age
5Tips for StudentsTry to memorize the gestational ages at which the markers of an intrauterine pregnancy appear….But more importantly, you should understand what is required to confirm an intrauterine pregnancyThis is how we rule out ectopic pregnancies and molar pregnanciesIf there is any possibility of an intrauterine pregnancy, you cannot give methotrexate or cytotecyou could cause an elective abortion
6Gestational sac Double decidual sign The first sign of an intrauterine pregnancyGestational sac Double decidual sign
7First sign of IUP: double decidual sign Earliest finding is the “double decidual sign” (arrows)seen around 4½-5 wks gestationinitially eccentric in locationIt excludes pseudogestational sac (free fluid or blood within endometrium)
9Double-decidual sign ( 5 weeks' menstrual age) Double-decidual sign ( 5 weeks' menstrual age). The decidua vera (dv) can be discerned from the decidua capsularis (dc) and chorion laeve surrounding the gestational sac. A small subchorionic hemorrhage(*) is present between the unopposed layers of decidua vera.
11Gestational Sac (confirmed by double decidual sign) Grows 1 mm per dayUsually seen by 4 ½ to 5 weeks of gestationDiscriminatory ß-hCG with TVUS (the level of ß-hCG above which you should be able to see a gestational sac on transvaginal ultrasound):Usually quoted ß-hCG IU/LAt AIMMC, we use 1500 IU/L
12Gestational Sac Discriminatory ß-hCG with transvaginal ultrasound : ß-hCG IU/LDiscriminatory ß-hCG with trans-abdominal ultrasound:≥ 6500 ß-hCG IU/LBhatt & Dogra, Radiol Clin N Am 45 (2007)
13The gestational sac diameter is used to calculate gestational age Long axisShort axis
15Second sign of IUP: Yolk Sac First structure visualized within the gestational sacRound , bright ringA definitive sign of IUPInvolutes after 11 weeksCan be seen half a week before normal embryo is seenWhen enlarged (“hydropic”), solid or duplicated, it is a very poor prognosis sign
16Gestational sac and yolk sac (5 weeks' menstrual age) Gestational sac and yolk sac (5 weeks' menstrual age). A normal yolk sac is visualized. The embryo is not identified. The decidua vera (dv) and decidua capsularis (dc) (double-decidual sign) are identified.
18Third sign of IUP: GS + yolk sac + embryo GS + yolk sac + fetal pole at 5½ to 6 wksThe fetal pole (arrow) is better seen on the zoomed in imageGS grows 1mm/dayEmbryo grows 1mm/day
19Fourth sign of intrauterine pregnancy Cardiac activtiy
20Fourth sign of IUP: GS + YS + embryo + cardiac activity Double decidual sign +yolk sac+ fetal pole +cardiac activityCardiac activity confirms a live intrauterine pregnancy (rules out a miscarriage)Cardiac activity is usually detected at 5 ½ to 6 weeks from last menstrual periodCRL ≥5 mm – fetal cardiac activity present
22Serum concentrations of ß-hCG in 443 normal pregnancies ß-hCG is first detected in maternal serum 6 to 9 days after conception. The levels rise in a logarithmic fashion, peaking 8 to 10 weeks after the last menstrual period, followed by a decline to a nadir at 18 weeks, with subsequent levels remaining constant until deliverySecond International Standard ß-hCGBraunstein G D, et al. Am J Obstet Gynecol 1976; 126:
23Serial ß-hCG The doubling time for a normal IUP is 2 days ß-hCG peaks at ~10 weeks gestationIt can get as high as 100,000 IU/LDoubling of ß-hCG is less reliable after 10 weeks gestation. At this time, pregnancy is better evaluated with U/S15% of normal IUPs can demonstrate an abnormal rise of ß-hCGKadar N, et al. Obstet Gynecol 1981;52:162-6
24ß-hCG up to mIU/mlThe minimal rise in ß-hCG for a viable pregnancy is 53% in 48 hoursThe minimal decline of a spontaneous abortion is 21-35% in 48 hoursA rise or fall in serial ß-hCG values that is slower than this is suggestive of an ectopic pregnancySeeber BE and Barnhart KT. Obstet Gynecol 2006;107:
25Seeber BE and Barnhart KT. Obstet Gynecol 2006;107:339-413 Hypothetical illustration of the rise, or fall, of serial hCG values in women with an EP53%21-35%Seeber BE and Barnhart KT. Obstet Gynecol 2006;107:
26Serum ProgesteroneProgesterone level of <10 ng/ml is consistent with an abnormal pregnancyProgesterone level of > 20 ng/ml is consistent with a normal pregnancyMcCord ML, et al. Fertil Steril 1996; 66:513-16
28Spontaneous abortion or miscarriage Spontaneous abortion is a fetal loss before 20 weeks gestation80% of miscarriages occur in the first trimester (first twelve weeks)Biochemical pregnancy:A woman has a positive pregnancy test, but does not miss a period (her period might come a few days late)The pregnancy has miscarried very early (~3wks gestation)Ferri: Ferri's Clinical Advisor 2012, 1st ed.
30BackgroundMiscarriage is the most common serious pregnancy complication affecting approximately 30% of biochemical pregnancies and 11–20% of clinically recognized pregnanciesThe diagnosis of miscarriage is made most commonly by trans-vaginal ultrasound (TVS) assessmentAfter a diagnosis of miscarriage, half of women undergo significant psychological effectsCecilia Bottomley, Tom Bourne. Diagnosing miscarriage. Best Practice & Research Clinical Obstetrics & Gynecology 2009; 23:463-77
31EtiologyApproximately 50–60% of first-trimester spontaneous abortions have karyotype abnormalitiesIgor N Lebedev, Nadezhda V Ostroverkhova, Tatyana V Nikitina, Natalia N Sukhanova and Sergey A Nazarenko. Features of chromosomal abnormalities in spontaneous abortion cell culture failures detected by interphase FISH analysis. European Journal of Human Genetics 2004; 12:513–20
32EtiologiesThe most frequent type of chromosomal abnormalities detected are:Autosomal trisomies ─ 52 %Monosomy X ─ 19 %Polyploidies ─ 22 %Other ─ 7 %Hsu, LYF. Prenatal diagnosis of chromosomal abnormalities through amniocentesis. In: Genetic Disorders and the Fetus, 4th ed, Milunsky, A (Ed), The Johns Hopkins University Press, Baltimore p.179
34Clinical classification of spontaneous abortion Laifer-Narin SL. Ultrasound for Obstetrics Emergencies. Ultrasound Clin ; 6:TypeDefinitionThreatened abortionVaginal bleeding during the first 20 weeks of pregnancy and no evidence of cervical dilation. <50% of threatened abortions will progress to loss of pregnancy.Missed abortionIntrauterine demise of the embryo without either vaginal bleeding or expulsion of the products of conception. Includes both an embryo with no heart tones (>7mm) or an empty gestational sac (>20mm).Incomplete abortionVaginal bleeding with dilation of the cervix and partial expulsion of products of conception.Complete abortionVaginal bleeding with expulsion of all of the products of conception.Inevitable abortionAbortion in progress with cervical dilation but the products of conception have not been expelled.
35Threatened Abortion Pregnant patient who is symptomatic with: Vaginal bleedingMild abdominal crampsClosed cervical osComplication affecting 16-25% of pregnant patientsIncreases her chance of spontaneous abortion, but <50% progress to pregnancy lossChung TKH. Aust N Z J Obstet Gynaecol 1999; 39:
36Differential Diagnosis of Threatened Abortion Undetermined or physiologic (implantation related)Ectopic pregnancySub-chorionic bleed, found in ~20% of threatened AbGestational trophoblastic disease (molar pregnancy)Impending spontaneous miscarriageCervix, vaginal or uterine pathology
37Ultrasound diagnosis of miscarriage This section is too in-depth for most medical students; read it for background, but you don’t necessarily have to memorize!Ultrasound diagnosis of miscarriage
38Comparison of international criteria Different organizations use different cutoffs to diagnose miscarriage…Comparison of international criteria
39TVS features of pregnancy failure Levine D. Radiology 2007; 245:Non visualization of the yolk sac by the time the mean sac diameter is 13 mm, orNon visualization of the embryo by the time the mean sac diameter is 20 mm, orNon visualization of cardiac activity by the time the embryo is 5 mm in length (~7wks gestation).Specificity for diagnosis of nonviable pregnancy is 100%
40Mean sac diameter greater than 20 mm and no embryonic contents, or How to define miscarriage using ultrasound-comparing and contrasting national guidelinesRoyal College of Obstetricians and Gynaecologists. The Management of Early Pregnancy Loss. Green-Top Guideline No. 25. October 2006Miscarriage:Mean sac diameter greater than 20 mm and no embryonic contents, orEmbryo crown-rump length > 6 mm with no heart beat, orIf sac remains empty after at least one week or still no cardiac activity 1 week after initial ultrasound
41Transvaginal Ultrasound Gestational sac > 20 mm How to define miscarriage using ultrasound-comparing and contrasting national guidelinesThe Institute of Obstetricians and Gynaecologists Royal College of Physicians of IrelandTransvaginal UltrasoundEmbryo > 7 mmNo cardiac activityMiscarriageGestational sac > 20 mmNo embryo or yolk sac
42What is the evidence to support the cut-offs used to diagnose miscarriage? UOG 2011 November, Jeve Y et al.Systematic review of ultrasound diagnosis of miscarriageProblems: studies are 15–20 years old, small study numbers, and various cut-off values used (4–6mm for CRL, 13–25mm for MSD), making pooling of data impossibleBest (most specific) criteria appeared to be MSD > 25mm with a missing embryo or MSD > 20mm with a missing yolk sacThese criteria had a 95% CI of 0.96–1.00, therefore up to 4 out of 100 diagnoses of early fetal demise may be wrong.A single incorrect diagnosis of miscarriage is one too manyA confidence interval (CI) is a particular kind of interval estimate of a population parameter and is used to indicate the reliability of an estimate.
43Prospective multicenter study 1060 patients of IPUV Conclusions Abdallah Y, et al. Limitations of current definitions of miscarriage using mean gestational sac diameter and crown–rump length measurements: a multicenter observational study. Ultrasound Obstet Gynecol 2011; 38: 497–502Prospective multicenter study1060 patients of IPUVConclusionsIn order to minimize the risk of a false-positive diagnosis of miscarriage the following cut-off could be introducedEmpty gestational sac or sac with a yolk sac but no embryo seen with MSD >25 mmEmbryo with an absent heartbeat and CRL > 7 mm
44Summary SummarySignificant interobserver variability may be associated with a misdiagnosis of miscarriageThis could result in interventions (D&C, misoprostol use) that could harm a viable pregnancyCurrent national guidelines should be reviewed to avoid inadvertent termination of wanted pregnancyLarge prospective studies with agreed reference standards are urgently required