Ultrasound Evaluation of First Trimester-B

ULTRASOUND EVALUATION OF FIRST TRIMESTER (cont.
Thursday, March 01, 2012
Ultrasound evaluation of first trimester
P/V bleeding in first trimester

Subchorionic bleeding Spontaneous abortion Ectopic pregnancy Gestational trophoblastic neoplasia(GTN)
Thursday, March 01, 2012 Ultrasound evaluation of first trimester 2
Spontaneous abortion
Threatened cervix closed Impending/inevitable open cervical OS Incomplete retained tissue trophoblastic flow Complete usually endometrium is empty
Spontaneous abortion: ultrasound findings

Spectrum from threatened to complete abortion normal abnormal gestational sac: o small, irregular, located in lower uterine segment or cervix o movement of sac up and down canal with uterine contractions large subchorionic hemorrhage fluid, debris within endometrial canal empty endometrial canal
Threatened abortion: ultrasound

Living embryo Dead embryo Empty gestational sac/blighted embryo Subchorionic haemorrhage Molar pregnancy Cervix is closed
Inevitable/Impending abortion
May get any/some of the findings in threatened abortion plus: Abnormal gestational sac: Small, irregular, located in lower uterine segment or cervix Movement of sac up and down in cervical canal with uterine contractions Open cervical canal
Deformed, irregular gestational sac
Open cervix: red arrow
Impending abortion
Impending abortion open cervix GS in cervix
movement of
sac
Incomplete abortion
Thickened, irregular endometrial stripe Echogenic retained products of conception Fetal parts Open cervical canal
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Retained products of conception: arrows
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Complete abortion
Endometrium is usually empty and endometrial stripe is usually normal There may be some little fluid/hemorrhage within the endometrium Cervical canal is closed
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Complete abortion: empty uterus
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Gestational Trophoblastic Neoplasia (GTN)

Spectrum including molar pregnancy, invasive mole, choriocarcinoma, & placental-site trophoblastic tumour (PSTT) Paternal karyotype
fertilization of chromosomally empty egg
Pts present with markedly elevated -HCG levels, nausea
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GTN: ultrasound findings

Heterogeneous, irregular endometrial mass
echogenicity variable cluster of grapes relatively late appearance vascular:
PSV,
RI
+ Myometrial invasion Fetus w/ a thick placenta Theca lutein cysts
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Molar pregnancy
Complete molar pregnancy: Chromosomal DNA exclusively paternal in origin Ovum with absent or inactive maternal chromosomes is fertilized by a normal haploid sperm Adiploid karyotype of 46,XX is produced (70-85%) No fetal development Placenta is entirely replaced by abnormal hydropic chorionic villi with excessive trophoblastic proliferation
Complete molar pregnancy: ultrasound
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Complete molar pregnancy: ultrasound
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Molar pregnancy: theca lutein cysts
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artial molar pregnancy

y Most result from fertilization of a normal ovum by 2
haploid sperms y Triploid karyotype pf 69,XXX; 69,XXY; or 69,XYY y Well developed but generally anomalous (triploid) fetal tissues y Hydropic degeneration of placental villi is focal, interspersed with normal placental villi y Trophoblastic proliferation is mild y Coexisting embryo/fetus/GS
artial molar pregnancy: ultrasound
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artial molar pregnancy: ultrasound
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Fetal anatomy in the first trimester

Normal anatomy Clear potential for early screening of congenital anomalies Developmental pitfalls Nuchal translucency
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Normal limb buds
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Choroid plexus
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Developmental pitfalls
Developing rhombencephalon normal finding contributes to development of 4th ventricle, brainstem, cerebellum cystic space in posterior fossa
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Rhombencephalon
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Developmental pitfalls
Fetal bowel normally herniates into the base of the umbilical cord in the first trimester
echogenic mass near cord
insertion
< 7 mm across base resolves by 12 wks
HYSIOLOGIC HERNIATION OF BOWEL
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Nuchal translucency
Thin membrane found at approx 10 wks GA along posterior neck > 3 mm is abnormal, esp. if septated
Ass. with trisomy 21,18; Turner s Syndrome risk of congenital anomalies even if karyotype is
normal Regression is not reassuring
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Normal nuchal translucency
2.6mm
2.7mm
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Abnormal nuchal translucency
4.5mm
Nuchal translucency
Should make this measurement in all obs ultrasound examinations between 10-14 wks Measure in neutral position Pitfalls
compression against uterine wall extension or flexion of fetal neck
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MATERNAL CAUSES OF PELVIC PAIN IN THE 1ST TRIMESTER
Hemorrhage / rupture of corpus luteum cyst Ovarian hyperstimulation syndrome Ovarian torsion
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Haemorrhagic cysts
Changes over time - ultimately resolves Thin wall (may be vascular) Increased through transmission No central blood flow
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Haemorrhagic cysts
Diffuse, low level echoes Lace-like or spider web pattern of internal echoes/septations Echogenic clot may be mobile or lenticular and adherent
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Ruptured cyst
Crenated appearance Adjacent free fluid
+/- internal debris
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Ovarian hyperstimulation syndrome

Complication of ovulation induction
incidence: pregnancy estradiol > 4000 pg/ml

Bilaterally enlarged, multi-cystic ovaries Complications include: cyst hemorrhage, cyst rupture, ovarian torsion
Ovarian hyperstimulation syndrome: ultrasound evaluation

Assess cysts for:
debris irregular shape adjacent free fluid
Document ovarian blood flow Assess for ascites, pleural effusion

Ovarian hyperstimulation syndrome: ultrasound evaluation
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Ovarian hyperstimulation syndrome: pleural effusion
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Ovarian torsion
Clinical presentation: acute onset of severe pelvic pain, usually no fever, normal WBC More common on right Differential diagnosis: hemorrhagic cyst, cyst rupture, renal colic, appendicitis
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Ovarian torsion: ultrasound features

Enlarged ovary
check for underlying mass heterogeneous central stroma
edema / infarct
peripheral cysts
+/- Free fluid Appearance quite variable

Ovarian torsion: Doppler findings

Variable
varying degrees of torsion

Decreased flow Reversed diastolic flow Decreased or absent venous flow Complete absence of flow
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Ultrasound Evaluation of First Trimester-B

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ULTRASOUND EVALUATION OF FIRST TRIMESTER (cont.

Thursday, March 01, 2012