First Trimester Complications

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

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

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

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. 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 Clinical Presentation

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

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 • 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 StudySagittal transvaginal uterine scan

22. Case StudyTransvaginal scan of the right adnexa

23. Case StudySagittal view of the right adnexa

24. Case StudyPower Doppler Right Adnexa

25. 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 Sonographic Differential

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

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 • 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 subchorionichematoma • 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

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 • 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 – “spauldingsign” • 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

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

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 • Small period 1 month s/p conception • Implantation bleed • Abortions • Chorioamnioticelevations • 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

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 Pregnancygestational 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

50. Hydatidiform Mole