first trimester complications
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First Trimester Complications. Fetal Biometry Workshop Day 1. Objectives. Review presentation , consequences & sonographic findings of ectopic pregnancy Discuss different types of abortion Define Blighted Ovum Review different types of molar pregnancy - PowerPoint PPT PresentationTRANSCRIPT
First Trimester Complications
Fetal Biometry WorkshopDay 1
Objectives
Review presentation , consequences & sonographic findings of ectopic pregnancyDiscuss different types of abortionDefine Blighted OvumReview different types of molar pregnancyIdentify coexisting maternal pelvic masses
Tubal Implantation
Abnormal tubesCongenitalPID***Tubal Surgery
Normal tubesTransmigration of ovumEmbryonic abnormalitiesHormonal imbalancePelvic massesIUDReduced tubal motility
Tubal Implantation
Hormonal Imbalance
EstrogenProgesterone
Tubal Implantation
MechanicalDevelopmental anomaliesInfectious damageTubal surgery
Cervical Implantation
Below level of internal osEndometrium unsuitable
EndometritisIUDRapid transit
Interstitial Implantation
Abdominal Implantation
PrimaryNormal tubes & ovaries
SecondaryTubal abortion with extension into peritoneal surface
Ovarian Implantation
Rare <0.52%Gestational sac occupy ovary position Gestational sac connected to uterus by uteroovarian ligamentOvarian tissue in wall of sacFailure of ovum to leave follicleTubal abortion implants on ovarian surface
Clinical Presentation
Vaginal spotting or bleedingAbdominal painAmenorrheaAdnexal tendernessPalpable adnexal mass+ Pregnancy test
hCGLower levels in ectopicRapid decrease
Hydatidiform moleNonviable pregnancy
Serum amylaseRuptured tubal pregnancy
Sonographic Protocol
Normal uterine pregnancy
GS – 4 to 5 weeks after LMP
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
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
Sonographic ProtocolUnruptured tubal pregnancy
Salpingotomy
Sonographic ProtocolRuptured tubal pregnancy
Sonographic Protocol
Chronic tubal pregnancy Blood + trophoblastic tissue + disrupted tubal tissue + inflammatory response = pelvic hematoceleIndefinite uterus sign – echogenicity similar to uterusMimics endometriosis and PID
Treatment Options
Surgical intervention Laparoscopy or laparotomySalpinectomyHysterectomyD & C
Non-Surgical interventionAdminister MethotrexateCuldocentesis
Treatment Options
Wait & See ApproachDecreasing hCGNo evidence of intrauterine pregnancyNo fetal heartbeatNo sign of bleeding or tubal rupture
Case StudySagittal transvaginal uterine scan
Case Study Transvaginal scan of the right adnexa
Case StudySagittal view of the right adnexa
Case StudyPower Doppler Right Adnexa
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
Abortion (AB)
Interruption of a pregnancyCauses of AB
InducedSpontaneous
Fetal malformationHormone inadequaciesDefective implantationPlacental maldevelopment or separationRh incompatibilitySystemic infection or toxic agentsMaternal traumaMultiple fibroids/submucosal fibroids
Varieties of AB
Spontaneous ABInevitable ABIncomplete ABComplete ABMissed ABSeptic AB
Spontaneous AB
Abortion before 20 weeks gestation Mostly 5th-12th week Vaginal bleeding
Possible no knowledge of pregnancy
May require D&CType
Threatened AB (clinical diagnosis)Vaginal bleeding in early pregMild crampingPossible visible fetusSac in Isthmus of uterusNot dilatation of cervix50% go on to abort
US findings of SAB
Check sac placementIt should be high for normal preg.
Check sac appearanceIs there a double decidual signUterine sizeMost likely there will be a recheck for any changes
Sono Findings - Poor Outcome
Abnormal Hi/Low hCGLarge subchorionic hematomaHeart rate <80 bpmAbnormal sac size/ embryo sizeSac size too small or too big compared to embryoDistorted sac shapeLow position in endometrial cavityBeware if heart beat seen, then this takes precedence to show live IUP over all the above
D&C
Dilatation and CurettageScraping of the endometriumCan leave scarring
Inevitable AB – In Progress
Incomplete AB
Partial evacuation of fetus and placentaSome retained products, Fetus expelledPlacenta usually remains
Signs & SymptomsUsually painBleeding/clottingD & C needed
Sonographic findingsStill increase in uterine sizeThick heterogeneous and echogenic endometrium w/hypervascularity
Complete AB
The entire pregnancy is totally expelled
Sonographic findingsIncrease in uterine sizeNo gestational sac or fetus seenDecidual reaction might still be visible
Missed AB
Sonographic findingsFetus doesn’t occupy whole uterusFetus may be macerated
Shapeless, ill defined echoes
Poor imagingNo amniotic fluid to delineate structures
Fetal demiseFetal 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 18-20 wks
Placenta remains attached
Amniotic fluid reabsorbed
Septic AB
Infected dead fetusMay show gas formationGas in uterus from bacteriaHow does gas show up on US?
Abortions
Threatened AB due to early abruption of placenta, can correct itselfspontaneous
Blighted Ovum
Anembryonic pregnancySac with no fetal polePositive beta hCGDifferent growth rates of GS
Small GS and large uterusIncreasing GS size and normal uterus
Blighted Ovum
Intrauterine sac with no fetal poleIrregular borders or ill definedLike a spontaneous or incomplete ABVaginal bleedingCheck sac size with LMP
Hemorrhage
Innocent bleedSmall period 1 month s/p conception
Implantation bleedAbortionsChorioamniotic elevations
Extrachorionic bleedUsually not serious concern
Subchorionic Blood accumulation between chorion & decidua vera
Subchorionic hematoma/hemorrhage
Subchorionic hematoma/hemorrhage
Pseudogestational Sac
Free fluid within the endometriumCan simulate an IUP early onTypically the sac size is irregular and there is not a pronounced double decidual sign
+/- slight echogenicity around the pseudo sacNo yolk sac and or fetal pole are signs of a pseudo sac
Other considerations for pelvic mass
Persistent corpus luteumPID/TOAAppendiceal abscessEndometriomaDermoidHydrosalpinxHemorrhagic or ruptured ovarian cystFluid filled bowelIn these cases what is an important ? To ask
Molar Pregnancy gestational trophoblastic disease
Increase in HCG x 10 for current age of pregnancyRemains elevated after 60 daysPrevious moleAssociated with
missed AB or blighted ovumTheca lutein cysts
Occur w/ 20-50% of molar pregnancyForm in response to increase HCGUsually large and multiloculatedBilateralResolve after mole removed
Molar Classification
Hydatidiform mole (complete)Partial moleCoexisting fetus and moleLocally invasive moleMetastatic choriocarcinoma
Hydatidiform Mole
Hydatidiform Mole
Partial Mole
Coexisting fetus and molar preg
By def.- dizygotic twin gestationMole complete or partialFetusCan become invasive
Locally Invasive Mole
Aka- chorioadenoma destruensInvasive but does not metastasizeBy def.- chorionic villi penetrate myometriumCan have invasion of bladder wall with hemorrhage of local vesselsExtensive proliferationVilli pattern preserved
Metastatic Mole Choriocarcinoma
Molar Pregnancy Symptoms
Vaginal bleeding may be present with painIncrease hCGLGA- rapid growthHyperemesis
This is the most common of all the symptoms
Signs of preeclampsia (HTN, proteinuria, edema)Theca lutein cystsVessicles passed vaginally (not typical)
Leiomyomas / fibroids
Common pelvic tumor (esp. >35 year old)Fibromuscular, most are benignEtiology
Ovarian hormone imbalanceFeed on estrogen and get larger
CharacteristicsVariable sizeVascular and can degenerateCan have central cystic necrosisCalcify over time Very dense
Leiomyomas
Presentation during pregnancy1Tri. Can cause SAB3Tri. Can interfere with delivery or precipitate preterm labor
SymptomsAsymptomaticIncrease sensation to urinatePainProfuse/prolonged bleedingEnlarged and irregular uterus
Sonographic findingsDepends on location, changes and internal characteristicsHypoechoic and heterogeneousRing of blood flowAttenuate soundCan look like molar pregnancy
Leiomyomas / fibroids
LeiomyomasLeiomyomas / fibroids
Cystic Hygroma
Cystic lymphangiomaAnomalous development in communication between venous system and lymphaticMostly benignLooks similar to meningomyelocele but no bony defectSonographic findings
Multi septated cystic massEvaluate spine for defect and herniating mass
Nuchal Translucency
11-13 weeks gestationDon’t get this mixed up with nuchal fold done later in pregnancy
Watch out for amnionShould be less than 3mmBounce
Fetal Demise
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 pregnancyThreatened abortionMissed abortionIncomplete abortionSpontaneous abortion
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?