1. First Trimester Complications
Fetal Biometry Workshop
Day 1

2. Objectives
Review presentation , consequences & sonographic findings of ectopic pregnancy
Discuss different types of abortion
Define Blighted Ovum
Review different types of molar pregnancy
Identify coexisting maternal pelvic masses

3. 6 – 12 weeks = embryonic period
5.5 weeks endovaginal detection – 2 mm
Fetal heart motion 5.3 – 5.5 weeks
Fetal heart is first organ to function with development completed by end of 8th week
Embryo initially seen as a thin linear structure adjacent to yolk sac
Organogenesis is approximately 10 weeks gestational age
A Teratogen = any agent that causes a structural abnormality following fetal exposure during pregnancy. The overall effect depends on dosage and time of exposure.
Absolute risk - the rate of occurrence of an abnormal phenotype among individuals exposed to the agent. (e.g. fetal alcohol syndrome)
Relative risk - the ratio of the rate of the condition among the exposed and the nonexposed. (e.g. smokers risk of having a low birth weight baby compared to non-smokers)
A high relative risk may indicate a low absolute risk if the condition is rare.
First trimester
5.5 weeks = small fetal pole with beating fetal heart

5. Tubal Implantation Abnormal tubes Normal tubes Congenital PID***
Tubal Surgery
Normal tubes
Transmigration of ovum
Embryonic abnormalities
Hormonal imbalance
Pelvic masses
IUD
Reduced tubal motility

6. Tubal Implantation
Hormonal Imbalance
Estrogen
Progesterone

7. Tubal Implantation Mechanical Developmental anomalies
Infectious damage
Tubal surgery

8. Cervical Implantation
Below level of internal os
Endometrium unsuitable
Endometritis
IUD
Rapid transit

9. Interstitial Implantation
Interstitial ectopic pregnancy. Coronal sonogram through the right cornu of the uterus shows the endometrium (arrowheads) extending into a inhomogeneous mass (M).

10. Abdominal Implantation
Primary
Normal tubes & ovaries
Secondary
Tubal abortion with extension into peritoneal surface

11. Ovarian Implantation Rare <0.52%
Gestational sac occupy ovary position
Gestational sac connected to uterus by uteroovarian ligament
Ovarian tissue in wall of sac
Failure of ovum to leave follicle
Tubal abortion implants on ovarian surface

12. Clinical Presentation
Vaginal spotting or bleeding
Abdominal pain
Amenorrhea
Adnexal tenderness
Palpable adnexal mass
+ Pregnancy test
hCG
Lower levels in ectopic
Rapid decrease
Hydatidiform mole
Nonviable pregnancy
Serum amylase
Ruptured tubal pregnancy

13. Sonographic Protocol Normal uterine pregnancy
GS – 4 to 5 weeks after LMP

14. 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

15. 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

16. Sonographic Protocol
Unruptured tubal pregnancy
Salpingotomy

17. Sonographic Protocol Ruptured tubal pregnancy
Case report: This is a 31-year-old woman with no significant medical history except for 2 normal previous pregnancies. This patient, using and IUD for contraception, was referred to our service because a mild pelvic pain and mild vaginal bleeding. The symptoms started three months ago and seemed to be accentuated in the last 15 days with recent deep dyspareunia and anal pain during defecation. Clinically, the low abdomen was sensitive. There was a small amount of vaginal bleeding. The uterus was in a normal size. There was a painful little mass in the cul-de-sac.
The serum HCG level was negative (< 4 UI/l), white blood cells were at with neutrophils, the C reactive protein was 13 (normal < 6) and sedimentation speed was 14/37. The following images were obtained. Due to the moderate pelvic pain, a laparoscopy had been performed, showing a hemoperitoneum with a rupture of the left tube. After salpingectomy, the histology revealed the presence of an ectopic pregnancy, associated with clots. The final diagnosis was left ectopic tubal pregnancy rupture with negative serum HCG level.
Note the non specific ultrasound aspect of the mass and the poor vascularization with energy Doppler

18. Sonographic Protocol Chronic tubal pregnancy
Blood + trophoblastic tissue + disrupted tubal tissue + inflammatory response = pelvic hematocele
Indefinite uterus sign – echogenicity similar to uterus
Mimics endometriosis and PID

19. Treatment Options Surgical intervention Non-Surgical intervention
Laparoscopy or laparotomy
Salpinectomy
Hysterectomy
D & C
Non-Surgical intervention
Administer Methotrexate
Culdocentesis

20. Treatment Options Wait & See Approach Decreasing hCG
No evidence of intrauterine pregnancy
No fetal heartbeat
No sign of bleeding or tubal rupture

21. Case Study Sagittal transvaginal uterine scan
A 20 year old woman presents with right adnexal tenderness and positive urinary beta- HCG test.
A normal uterine stripe is seen. A small, rounded anechoic area, adjacent to the endometrial canal is noted; this is too small to represent an 8 week gestational sac. Also, no appreciable decidual reaction is seen, so it is not a decidual cyst
the presence of a small anechoic area with barely perceptible walls, adjacent to the endometrial cavity. This may represent a simple endometrial cyst or a decidual cyst. The presence of decidual cysts is now known to be associated with ectopic pregnancy. Since no appreciable decidual reaction is seen, decidual cyst is less likely and it may be a simple endometrial cyst.

22. Case Study Transvaginal scan of the right adnexa
Sagittal view demonstrating a gestational sac with an embryo [of 8 weeks size]. No cardiac activity was noted. Complex free fluid was identified.

23. Case Study Sagittal view of the right adnexa
Normal right ovary is seen, with the ectopic gestational sac demonstrating a highly echogenic rim enclosing the embryo [tubal ring sign].

24. Case Study Power Doppler Right Adnexa
Vascular flow around an ectopic is variable and depends on the amount of trophoblastic tissue.
The case shown here demonstrates the classical "ring of fire" sign seen on color Doppler studies in cases of ectopic gestation.
Trophoblastic flow is characterized by high velocity systolic flow, and low resistance diastolic flow when seen in an extrauterine location. However, most studies now conclude that color Doppler does not significantly increase the diagnostic accuracy in cases of ectopic gestation, but can be used as a supplemental test to detect ectopic trophoblastic flow.

25. 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

27. Abortion (AB) Interruption of a pregnancy Causes of AB Induced
Spontaneous
Fetal malformation
Hormone inadequacies
Defective implantation
Placental maldevelopment or separation
Rh incompatibility
Systemic infection or toxic agents
Maternal trauma
Multiple fibroids/submucosal fibroids

28. Varieties of AB Spontaneous AB Inevitable AB Incomplete AB Complete AB
Missed AB
Septic AB
Most losses are secondary to chromosomal anomalies
Approx 50% pregnancies don’t make it
Women just don’t realize they are pregnant

29. Spontaneous AB Abortion before 20 weeks gestation Mostly 5th-12th week
Vaginal bleeding
Possible no knowledge of pregnancy
May require D&C
Type
Threatened AB (clinical diagnosis)
Vaginal bleeding in early preg
Mild cramping
Possible visible fetus
Sac in Isthmus of uterus
Not dilatation of cervix
50% go on to abort

30. US findings of SAB Check sac placement Check sac appearance
It should be high for normal preg.
Check sac appearance
Is there a double decidual sign
Uterine size
Most likely there will be a recheck for any changes

31. Sono Findings - Poor Outcome
Abnormal Hi/Low hCG
Large subchorionic hematoma
Heart rate <80 bpm
Abnormal sac size/ embryo size
Sac size too small or too big compared to embryo
Distorted sac shape
Low position in endometrial cavity
Beware if heart beat seen, then this takes precedence to show live IUP over all the above

32. D&C Dilatation and Curettage Scraping of the endometrium
Can leave scarring

33. Inevitable AB – In Progress
Signs & Symptoms
Vaginal bleeding
Cervical dilatation
Uterine contractions
Sonographic findings
Cervix widened and fluid filled
Low lying gestational sac
May be fluid around sac at detachment
Imminent abortion
Impending abortion
Bleeding profusely
Cervix softened and dilated

34. Incomplete AB Partial evacuation of fetus and placenta
Some retained products, Fetus expelled
Placenta usually remains
Signs & Symptoms
Usually pain
Bleeding/clotting
D & C needed
Sonographic findings
Still increase in uterine size
Thick heterogeneous and echogenic endometrium w/hypervascularity

35. Complete AB The entire pregnancy is totally expelled
Sonographic findings
Increase in uterine size
No gestational sac or fetus seen
Decidual reaction might still be visible

36. Missed AB Sonographic findings Fetal demise
Fetus doesn’t occupy whole uterus
Fetus may be macerated
Shapeless, ill defined echoes
Poor imaging
No amniotic fluid to delineate structures
Fetal demise
Fetal 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 wks
Placenta remains attached
Amniotic fluid reabsorbed
Macerated = to make soften

37. Septic AB Infected dead fetus May show gas formation
Gas in uterus from bacteria
How does gas show up on US?

38. Abortions
Threatened AB due to early abruption of placenta, can correct itself
spontaneous

39. Blighted Ovum Anembryonic pregnancy Sac with no fetal pole
Positive beta hCG
Different growth rates of GS
Small GS and large uterus
Increasing GS size and normal uterus
A blighted ovum, also called an "anembryonic pregnancy", is a fertilized egg which implants in the uterus, and begins to devlop a gestational sac. The fertilized egg, however, fails to form beyond the sixth week and is absorbed back into the uterus.
The placenta continues to grow, and the body is usually slow to catch on that the pregnancy is gone. There may be no bleeding to signal a problem; later, the woman may notice a brown discharge. Sometimes a woman will have a loss without ever knowing she was pregnant. Others will discover the pregnancy and all will appear well throughout much if not all of the first trimester. She may not realize she has a blighted ovum until her healthcare provider fails to detect a heartbeat or an ultrasound reveals an empty gestational sac. Since the placental tissue generates the making of pregnancy hormones, many women with a blighted ovum "feel pregnant" but are destined to lose the pregnancy.
In most liklihood the reason for a blighted ovum is random chromosomal accident (further research suggests a 4 in 5 chance that the cause is chromosomal in this situation). In some cases, the egg or the sperm may be of poor quality. The age of the parents may contribute to this factor although this diagnosis happens to all ages. Occasionally the cause may be something other than chromosomal, such as low hormone levels. This is rare but in these cases a treatable condition might be the cause. For example, a low hormone level may have caused early termination of the pregnancy. In these cases, hormone pills such as progesterone may work

41. Blighted Ovum Intrauterine sac with no fetal pole
Irregular borders or ill defined
Like a spontaneous or incomplete AB
Vaginal bleeding
Check sac size with LMP

42. Hemorrhage Innocent bleed Implantation bleed Abortions
Small period 1 month s/p conception
Implantation bleed
Abortions
Chorioamniotic elevations
Extrachorionic bleed
Usually not serious concern
Subchorionic
Blood accumulation between chorion & decidua vera

43. Subchorionic hematoma/hemorrhage

44. Subchorionic hematoma/hemorrhage

45. Pseudogestational Sac
Free fluid within the endometrium
Can simulate an IUP early on
Typically the sac size is irregular and there is not a pronounced double decidual sign
+/- slight echogenicity around the pseudo sac
No yolk sac and or fetal pole are signs of a pseudo sac
Typically a pseudo-gestational sac is simply a small focal accumulation of fluid within the uterine cavity.

46. Other considerations for pelvic mass
Persistent corpus luteum
PID/TOA
Appendiceal abscess
Endometrioma
Dermoid
Hydrosalpinx
Hemorrhagic or ruptured ovarian cyst
Fluid filled bowel
In these cases what is an important ? To ask

47. Molar Pregnancy gestational trophoblastic disease
Increase in HCG x 10 for current age of pregnancy
Remains elevated after 60 days
Previous mole
Associated with
missed AB or blighted ovum
Theca lutein cysts
Occur w/ 20-50% of molar pregnancy
Form in response to increase HCG
Usually large and multiloculated
Bilateral
Resolve after mole removed

48. Molar Classification Hydatidiform mole (complete) Partial mole
Coexisting fetus and mole
Locally invasive mole
Metastatic choriocarcinoma

49. Hydatidiform Mole
Trophoblastic proliferation into mass/tumor made up of many cells
Degeneration of chorionic villi in the absence of normal circulation
Villi become hydropic (fluid engorged)
Grapelike clusters
Usually benign but can become malignant
2n chromosome makeup
Fetal parts not seen

50. Hydatidiform Mole 1Tri. Missed AB, incomplete AB, blighted ovum
Small vessicles may appear echogenic
2Tri.
Vessicles are larger and have classic appearance
Theca lutein cysts
Due to what?

51. Partial Mole By definition- chorionic villi are edematous not prolific
2 sperms fertilize a single ovum and results in making fetal parts
69xxx,69xxy, 69xyy
Fetal tissue present although grossly abnormal
Some will have normal placenta
3n chromosome make up
May be difficult to distinguish partial from complete
No change to malignant form

52. Coexisting fetus and molar preg
By def.- dizygotic twin gestation
Mole complete or partial
Fetus
Can become invasive

53. Locally Invasive Mole Aka- chorioadenoma destruens
Invasive but does not metastasize
By def.- chorionic villi penetrate myometrium
Can have invasion of bladder wall with hemorrhage of local vessels
Extensive proliferation
Villi pattern preserved

54. Metastatic Mole Choriocarcinoma
Aka-
Most severe form
Rapid spread to myometrium and local vessels
Bleeding, necrosis, and tumor hemolisis
Mets to liver, brain, lungs, bone, GI tract, and skin
High degree of trophoblastic proliferation which masks the villous pattern.

55. Molar Pregnancy Symptoms
Vaginal bleeding may be present with pain
Increase hCG
LGA- rapid growth
Hyperemesis
This is the most common of all the symptoms
Signs of preeclampsia (HTN, proteinuria, edema)
Theca lutein cysts
Vessicles passed vaginally (not typical)

56. Leiomyomas / fibroids Common pelvic tumor (esp. >35 year old)
Fibromuscular, most are benign
Etiology
Ovarian hormone imbalance
Feed on estrogen and get larger
Characteristics
Variable size
Vascular and can degenerate
Can have central cystic necrosis
Calcify over time
Very dense

57. Leiomyomas Leiomyomas / fibroids Presentation during pregnancy
1Tri. Can cause SAB
3Tri. Can interfere with delivery or precipitate preterm labor
Symptoms
Asymptomatic
Increase sensation to urinate
Pain
Profuse/prolonged bleeding
Enlarged and irregular uterus
Sonographic findings
Depends on location, changes and internal characteristics
Hypoechoic and heterogeneous
Ring of blood flow
Attenuate sound
Can look like molar pregnancy

58. Leiomyomas / fibroids
Leiomyomas

59. Cystic Hygroma Cystic lymphangioma
Anomalous development in communication between venous system and lymphatic
Mostly benign
Looks similar to meningomyelocele but no bony defect
Sonographic findings
Multi septated cystic mass
Evaluate spine for defect and herniating mass

61. Nuchal Translucency 11-13 weeks gestation Watch out for amnion
Don’t get this mixed up with nuchal fold done later in pregnancy
Watch out for amnion
Should be less than 3mm
Bounce

66. Fetal Demise

67. 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 pregnancy
Threatened abortion
Missed abortion
Incomplete abortion
Spontaneous abortion

68. 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?