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First Trimester Bleeding

First Trimester Bleeding. ACR Appropriateness Criteria Bruce Hall, M.D. Expert Panel on Women’s Imaging. Involved experts from 17 academic centers, including MGH, Brigham, Dartmouth-Hitchcock. Double decidual sign Intradecidual sign. Intrauterine Fluid Collection.

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First Trimester Bleeding

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  1. First Trimester Bleeding ACR Appropriateness Criteria Bruce Hall, M.D.

  2. Expert Panel on Women’s Imaging • Involved experts from 17 academic centers, including MGH, Brigham, Dartmouth-Hitchcock.

  3. Double decidual sign Intradecidual sign

  4. Intrauterine Fluid Collection • Double Decidual Sign: 100% specific but only 64% sensitive • Intradecidual Sign: 97-100% specific, 60-68% sensitive ****The absence of a double decidual sign or intradecidual sign does not exclude an intrauterine pregnancy. **** Be cautious when calling an intrauterine collection a “pseudosac”. Many “pseudosacs” develop into normal IUPs.

  5. HCG discriminatory level • Previously accepted: If the serum HCG level is 1000-2,000 mIU/ml, using an endovaginal probe, one should see a gestational sac. • Because of human variation, multiple gestation, technical issues and operator dependency, not always true. • Currently accepted: One may not see a gestational sac until HCG > 2,000 **** So, in a stable patient, recommend HCG and US f/u.

  6. Yolk Sac and Fetal Pole Peviously accepted: If MSD of GS > 8mm, one should see yolk sac. If MSD of GS > 16mm, one should see a fetal pole. 4.4% false positive rate. 19% variability in measurement Current recommendation: If MSD of GS > 25mm one should see a fetal pole. If MSD 8-25 mm and no yolk sac or fetal pole, do f/u US in 7-10 days. If no yolk sac or fetal pole on f/u=early pregnancy loss.

  7. Fetal Cardiac Activity • Previously accepted: If fetal CRL 4-5mm, one should see fetal cardiac activity. • Currently accepted: If CRL > /= 7mm one should see fetal cardiac activity. If no FH with CRL between 4-7mm, do a f/u US in 7-10 days. If no FH on f/u US = early pregnancy loss. • M-mode only. Avoid Doppler due to potential for temperature elevation.

  8. Ectopic Pregnancy 80% of tubal pregnancies on same side as the CL, so important to distinguish between the two. • CL varies in appearance: cyst, complex cyst or solid. • CL with Doppler: “ring of fire”, • Pressure with EV probe can help to distinguish CL from extraovarian mass. CL moves with the ovary. • Ectopic more echogenic than CL.

  9. Ectopic Pregnancy • Vascularity of ectopic is variable. May not be vascular. • Free fluid with solid material (blood clot) highly suggestive. • Image the flanks, paracolic gutters. • MRI may be useful for unusual ectopics (cornual or cervical), but only in a stable patient

  10. Pregnancy of Unknown Location • Positive HCG and no visible pregnancy • Only 8% of these turn out to be ectopics • The majority have had a spontaneous abortion. • Remainder are turn out to be living IUPs, so if stable, close monitoring favored over D&C • If HCG rises to > 1000 to 2000 mIU/ml, do US • If HCG plateaus, ectopic likely. Do US or Rx Mtx if US neg. • HCG may also rise or plateau in setting of retained POC

  11. Minor Issues • Nipple not areolar margin • NT +/- First Trimester US • NTQR vs Fetal Medicine Foundation. 7 sonographers are now certified • Digital mammography at HVMA • Tomosynthesis

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