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1 st TRIMESTER PREGNANCY FAILURE Shortened to emphasize medical student curriculum requirements

1 st TRIMESTER PREGNANCY FAILURE Shortened to emphasize medical student curriculum requirements. Carlos M. Fernandez, M.D Department of Obstetrics and Gynecology Advocate Illinois Masonic and Medical Center . Ultrasound diagnosis of intrauterine pregnancy. Diagnosis of IUP.

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1 st TRIMESTER PREGNANCY FAILURE Shortened to emphasize medical student curriculum requirements

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  1. 1st TRIMESTER PREGNANCY FAILUREShortened to emphasize medical student curriculum requirements Carlos M. Fernandez, M.D Department of Obstetrics and Gynecology Advocate Illinois Masonic and Medical Center

  2. Ultrasound diagnosis of intrauterine pregnancy

  3. Diagnosis of IUP Seeber BE and Barnhart KT. Obstet Gynecol 2006;107:339-413 “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 wks CRL >5 mm – fetal cardiac activity present

  4. First sign of IUP: double decidual sign • Earliest finding is the “double decidual sign” (arrows) • seen around 4½-5 wks gestation • initially eccentric in location • It excludes pseudogestational sac (free fluid or blood within endometrium)

  5. Gestational Sac (confirmed by double decidual sign) • Grows 1 mm per day • Usually seen by 4 ½ to 5 weeks of gestation • Discriminatory ß-hCG with TVS: usually quoted 1000 - 2000 ß-hCG IU/L. Depends upon: • Skill of the sonographer and image magnification • Frequency (5-10mHz) and resolution of the transducer • Uterine abnormalities, fibroids • Multiple gestation

  6. Gestational Sac Bhatt & Dogra, Radiol Clin N Am 45 (2007) 549-560 Discriminatory ß-hCG with TVS: 1000 - 2000 ß-hCG IU/L Discriminatory ß-hCG with TAS: ≥ 6500 ß-hCG IU/L

  7. The gestational sac diameter is used to calculate gestational age Long axis Short axis

  8. Second sign of IUP: Yolk Sac • First structure visualized within the gestational sac • Round , bright ring <6mm • A definitive sign of IUP • Involutes after 11 weeks • Can be seen half a week before normal embryo is seen • When enlarged (“hydropic”), solid or duplicated, it is a very poor prognosis sign

  9. Third sign of IUP: GS + yolk sac + embryo • GS + yolk sac + fetal pole at 5½ to 6 wks • The fetal pole (arrow) is better seen on the zoomed in image • GS grows 1mm/day • Embryo grows 1mm/day

  10. Fourth sign of IUP: GS + YS + embryo + cardiac activity • Double decidual sign +yolk sac+ fetal pole +cardiac activity • Cardiac activity confirms a live intrauterine pregnancy • Cardiac activity is usually detected at 5 ½ to 6 weeks from last menstrual period • CRL ≥5 mm – fetal cardiac activity present

  11. Bhcg and progesterone in early pregnancy

  12. Serum 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 delivery Second International Standard ß-hCG Braunstein G D, et al. Am J Obstet Gynecol1976; 126:678-81.

  13. Serial ß-hCG Kadar N, et al. Obstet Gynecol 1981;52:162-6 The doubling time for a normal IUP is 2 days, with a range of 1.4 to 2.1 days Doubling of ß-hCG is less reliable after 10,000 mIU/ml , at this level pregnancy is better evaluated with U/S 15% of normal IUPcan demonstrate an abnormal rise of ß-hCG

  14. ß-hCG up to 10000 mIU/ml Seeber BE and Barnhart KT. Obstet Gynecol 2006;107:339-413 The minimal rise in ß-hCG for a viablepregnancyis 53% in 48 hours The minimal decline of a spontaneous abortionis 21-35%in 48 hours A rise or fall in serial ß-hCG values that is slower than this is suggestive of an ectopic pregnancy

  15. Hypothetical illustration of the rise, or fall, of serial hCG values in women with an EP 53% 21-35% Seeber BE and Barnhart KT. Obstet Gynecol 2006;107:339-413

  16. Spontaneous abortion: background, etiology

  17. Spontaneous abortion or miscarriage Spontaneous abortion is a fetal loss before week 20 of pregnancy Early loss is before menstrual week 12 Late loss refers to losses from weeks 12 to 20 80% of miscarriages occurring in the first trimester Ferri: Ferri's Clinical Advisor 2012, 1st ed.

  18. Miscarriage Cecilia Bottomley, Tom Bourne. Diagnosing miscarriage. Best Practice & Research Clinical Obstetrics & Gynecology2009; 23:463-77 Miscarriage is the most common serious pregnancy complication affecting approximately 30% of biochemical pregnancies and 11–20% of clinically recognized pregnancies The diagnosis of miscarriage is made most commonly by trans-vaginal ultrasound (TVS) assessment After a diagnosis of miscarriage, half the women undergo significant psychological effects, which may last for up to 12 months

  19. Miscarriage Igor 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 • The crucial role of chromosomal imbalance in abnormal early human development is well established • Approximately 50–60% of first-trimester spontaneous abortions have karyotype abnormalities

  20. Miscarriage 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 1998. p.179 • The most frequent type of chromosomal abnormalities detected are: • Autosomal trisomies ─ 52 % • Monosomy X ─ 19 % • Polyploidies ─ 22 % • Other ─ 7 %

  21. Classification of miscarriage

  22. Clinical classification of spontaneous abortion Laifer-Narin SL. Ultrasound for Obstetrics Emergencies. Ultrasound Clin . 2011; 6: 177-193

  23. Differential Diagnosis ofThreatened Abortion • Undetermined or physiologic (implantation related) • Ectopic pregnancy • Sub-chorionic bleed, found in ~20% of threatened Ab • Gestational trophoblastic disease • Impending spontaneous miscarriage • Cervix, vaginal or uterine pathology

  24. This section is too in-depth for most medical students; use it only for the most interested students! Ultrasound diagnosis of miscarriage (comparing international criteria)

  25. How to define miscarriage using ultrasound-comparing and contrasting national guidelines Royal College of Obstetricians and Gynaecologists. The Management of Early Pregnancy Loss. Green-Top Guideline No. 25. October 2006 • Miscarriage: • Miscarriage is defined at first scan when gestational sac with MSD greater than 20 mm an no embryonic contents or CRL > 6 mm with no heart beat • Or subsequently if sac remain empty after at least one week or still no cardiac activity 1 week after initial

  26. How to define miscarriage using ultrasound-comparing and contrasting national guidelines The Institute of Obstetricians and GynaecologistsRoyal College of Physicians of Ireland

  27. What is the evidence to support the cut-offs used to diagnose miscarriage? Conclusions • First systematic review of ultrasound diagnosis of miscarriage • Studies are 15–20 years old, small numbers of miscarriage, reference standards were poor (method of miscarriage confirmation) • Various cut-off values used (4–6mm for CRL, 13–25mm for MSD), making pooling of data impossible • Best (most specific) criteria appeared to be MSD > 25mm with a missing embryo or MSD > 20mm with a missing yolk sac • These criteria had a 95% CI of 0.96–1.00, therefore up to 4 out of 100diagnoses of early fetal demise may be wrong. A single incorrect diagnosis of miscarriage is one too many Jeve Y et al., UOG 2011 Nov

  28. 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: 497–502 • Prospective multicenter study • 1060 patients of IPUV Conclusions • Current definitions used to diagnose miscarriage by ultrasound are potentially unsafe • In order to minimize the risk of a false-positive diagnosis of miscarriage the following cut-off could be introduced • Empty gestational sac or sac with a yolk sac but no embryo seen with MSD >25 mm • Embryo with an absent heartbeat and CRL > 7 mm

  29. SummarySummary • Data from these studies show that current definitions used to diagnose miscarriage are potentially unsafe • Significant interobserver variability may be associated with a misdiagnosis of miscarriage • Current national guidelines should be reviewed to avoid inadvertent termination of wanted pregnancy • Large prospective studies with agreed reference standards are urgently required

  30. Ectopic pregnancy

  31. Risk Factors for Ectopic Pregnancy Prior ectopic Previous tubal surgery History of tubal ligation Intra-uterine contraceptive device History of infertility History of PID History of chlamydia or gonorrhea Smoking

  32. Pregnancy of uknown location

  33. Retained products of conception

  34. Retained Products of Conception (RPOC) Oscar Sadan, Abraham Golan, Ofer Girtler, Samuel Lurie, Abraham Debby, Ron Sagiv, Shmuel Evron, Marek Glezerman. Role of Sonography in the Diagnosis of Retained Products of Conception. JUM 2004 23:371-4 RPOC are well-known and troublesome complications after spontaneous or induced abortion and parturition Patients usually have abdominal pain, bleeding, fever, and an open cervical external os The diagnosis is based on the sonographic appearance of intrauterine echogenic material Retained products of conception are generally treated by D&C to empty the uterine cavity. This exposes the uterus to additional potential trauma, with immediate risks such as bleeding, perforation, and infection and late sequelae such as intrauterine adhesions

  35. Retained products of conception. Intrauterine heterogeneous, mixed echogenic mass with marked internal vascularity in a patient who recently underwent spontaneous abortion

  36. Transvaginal sagittal sonogram of a uterus immediately after repeated D&C. A thin hyperechoic echo is shown, characteristic of an empty uterus.

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