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OB > 1st Trimester Complications > Flashcards

1st Trimester Complications Flashcards

1
Q

Based on what hCG values should a pregnancy be seen using transvaginal US?

A

800 to 1000 IU/L based on 2IS (second international standard)
1000 to 2000 IU/L based on first IRP (first international reference preparation)

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2
Q

Normal intrauterine pregnancy under 7 weeks demonstrates __ of quantitative maternal serum hCG levels every 3.5 days; or increase __% in hCG levels within __hours.

A

Normal intrauterine pregnancy under 7 weeks demonstrates doubling of quantitative maternal serum hCG levels every 3.5 days; or increase 66% in hCG levels within 48 hours.

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3
Q

When do hCG levels plateau and subsequently decline while gestation continues to grow?

A

9-10 weeks

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4
Q

With what pathology do hCG levels plateau later and fall much more slowly?

A

trisomy 21

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5
Q

How can hCG be used as a screening marker for trisomy 21?

What subunit is most sensitive for this pathology?

A

hCG will be increased during 1st and 2nd trimesters; but cannot be used by itself to diagnose.
beta subunit

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6
Q

Normally, pregnancy-associated plasma protein (PAPP-A) does what with advancing gestation?

A

increases

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7
Q

What does PAPP-A do with trisomy 21?

A

is initially lower than normal, but decreases with advancing gestation

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8
Q

At what gestational age is PAPP-A the strongest biochemical marker for trisomy 21?

A

9-11 weeks

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9
Q

What is the most emergent diagnoses made with sonography?

A

ectopic pregnancy

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10
Q

What percentage of ectopic pregnancies take place in the fallopian tubes? In the ampula?

A

95-99% in fallopian tubes

70% in ampula

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11
Q

What are the risk factors for ectopic pregnancy?

A

rise in incidence of pelvic infections, use of IUDs (having IUD while pregnant), infertility treatments, history of ectopic pregnancies, fallopian tube surgeries, disruption of normal tubal pathways (scarring, endometriosis)

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12
Q

What is the most important risk factor for ectopic pregnancy?

A

history of ectopic pregnancy

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13
Q

Clinical Symptoms for ectopic pregnancy:

A

vaginal bleeding, positive pregnancy test, back pain, shock symptoms, abnormal hCG levels

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14
Q

Other than in fallopian tubes, where can ectopic pregnancies take place?

A

ovary, broad ligament, peritoneum, cervix and cornua

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15
Q

Sonographic findings for ectopic pregnancy:

A

pseudogestational sac with homogeneous level echoes, empty uterus, presence of adnexal mass, echogenic free fluid in POD

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16
Q

What is a pseudogestational sac?

A

does not contain either living embryo or yolk sac; centrally located within endometrial cavity (vs burrowed sac that is eccentrically located), has homogeneous echoes

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17
Q

Extrauterine gestational sacs often demonstrate:

A

thickened echogenic ring (trophoblastic tissue)

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18
Q

Risk of ectopic pregnancy can be greater than __% when intrauterine gestation absent and there is corresponding adnexal mass

A

90%

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19
Q

What is correlated with an increased risk of ectopic?

A

moderate to large amounts of free intraperitoneal fluid and associated adnexal mass

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20
Q

What is the most life-threatening of all ectopic gestations?

A

interstitial pregnancy (at segment of fallopian tube that enters uterus)

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21
Q

What makes interstitial ectopic such a dangerous location?

A

involves parauterine and myometrial vasculature, creating life threatening hemorrhage when rupture occurs

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22
Q

What type of ectopic has an increased risk of complete hysterectomy? Why?

A

cervical pregnancy

because of uncontrollable bleeding caused by increased vascularity of cervix

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23
Q

Name the different location of ectopic pregnancies.

A

ovarian, peritoneal, tubal, isthmic, and cervical

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24
Q

What is the most common presentation for complication?

A

first trimester bleeding

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25
Q

Why would bleeding occur in the first trimester?

A

normal implantation, ectopic pregnancy, spontaneous abortion, subchronic hemorrhage

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26
Q

Pregnancy is unlikely to progress if bleeding is accompanied by…

A

severe pain, uterine contractions, dilated cervix

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27
Q

___% of pregnancies result in 1st trimester spontaneous abortion. When does this occur?

A

15-20%

happens in first 6-8 weeks

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28
Q

List the five types of abortions.

A

complete, incomplete, threatend, missed, and inevitable

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29
Q

Describe each type of abortion: complete, incomplete, threatend, missed, and inevitable

A

complete: expulsion of all products of conception(POC)
incomplete: partial expulsion of POC
inevitable: no expulsion of POC, open cervix, contractions, no progression
threatened: bleeding, no expulsion of POC, cervix closed, pregnancy may progress
missed: no expulsion of POC, complete retention of POC

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30
Q

What is an abortus?

A

fetus exposed prior to 20 weeks or less than 500g

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31
Q

Sonographic findings of incomplete spontaneous abortion:

A

ranges from intact gestational sac with nonviable embryo to collapsed gestational sac grossly misshapen

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32
Q

Sonographic signs for retained products:

A

thickened endometrium ( >8mm), increased vascularization of endometrial complex (color doppler strongly predictive)

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33
Q

What are signs of a spontaneous abortion?

A

presence of visible embryonic parts, gestational sac, embryonic disc, obvious evidence of retained products of conception, no heart activity

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34
Q

What is the most common occurrence of bleeding in first trimester?

A

subchorionic hemorrhage

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35
Q

How does a subchorionic hemorrhage occur?

A

the low pressure bleed results from the process of implantation of fertilized ovum into endometrial cavity and myometrial wall

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36
Q

Where is a subchorionic hemorrhage found?

A

between myometrium and margins of gestational sac (between chorion and wall of uterine cavity)?

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37
Q

Clinical Symptoms for subchorionic hemorrhage:

A

bleedings, spotting or uterine cramping; if hemorrhage becomes large enough, can lead to spontaneous abortion

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38
Q

Sonographic finding for subchorionic hemorrhage:

A

early bleed: slightly echogenic as RBC actively fill area of hemorrhage
with time, becomes more anechoic; avascular

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39
Q

If a patient has a positive pregnancy test, but a normal uterus/endometrium with no gestational sac, what should be suspected?

A

very early intrauterine pregnancy (between 3 and 5 weeks), nondeveloping pregnancy, ectopic pregnancy

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40
Q

Sonographic findings for absent intrauterine sac:

A

empty uterus with no evidence for endometrial fluid collection, absence of adnexal masses or ff, positive beta-hCG level

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41
Q

How fast does a normal intrauterine sac grow? How fast does a normal embryo grow?

A

1mm per day in the first trimester

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42
Q

At what size should the gestational sac be to see the yolk sac transvaginally?

A

8mm in size

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43
Q

When should the embryo be visualized?

A

when the MSD is greater than 16 mm

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44
Q

Differentials of gestational sac without embryo or yolk sac:

A

normal early intrauterine pregnancy less than 5 weeks, abnormal intrauterine pregnancy, pseudogestational sac in patient with ectopic

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45
Q

Criteria for abnormal sac:

A

lack of appropriate growth indicates abnormal sac; if embryo not detected at 6.4 weeks, diagnosis of spontaneous pregnancy loss can be made

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46
Q

What is a blighted ovum/anembryonic pregnancy?

A

gestational sac in which embryo fails to develop or stops developing at such early stage that it is imperceptible by US

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47
Q

What happens to the gestational sac with a blighted ovum?

A

continues to grow

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48
Q

Sonographic findings for blighted ovum:

A

large, empty gestational sac; no yolk sac, amnion, or embryo; MSD increases by 0.7mm/day (normal=1.13mm/day)

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49
Q

Findings in a gestational sac associated with abnormal intrauterine pregnancies include:

A

absence of cardiac motion in embryo 5mm or larger, absence of cardiac motion after 6.5 menstrual weeks, large yolk sac or amnion without visible embryo, calcified yolk sac;
gestational sac greater than 18mm and lacking viable embryo, gestational sac greater than 8mm and lacking visible yolk sac, irregular/misshapen sac, sac in the position of cornula, low or hourglassing through cervical os;
irregular trophoblastic reaction, absent double decidual sac finding, thin trophoblastic reaction (less than 2mm), intratrophoblastic venous flow, gestational sac growth of less than .6mm/day, absent embryonic growth, discrepancy in sac size with hCG level

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50
Q

What is gestational trophoblastic disease?

A

proliferative disease of trophoblast after abnormal conception

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51
Q

benign form of gestational trophoblastic disease include:

A

hydatidiform mole (partial, complete, coexistent)

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52
Q

malignant form of gestational trophoblastic disease include:

A

invasive mole or choriocarcinoma

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53
Q

Clinically, what does gestational trophoblastic disease look like?

A

vaginal bleeding, beta hCG dramatically elevated (>100,000), severe nausea/vomiting (hyperemesis gravidarum), low AFP levels

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54
Q

What is a complete molar pregnancy?

A

occurs when egg without nucleus is fertilized by one normal sperm

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55
Q

Sonographic findings for complete mole:

A

snowstorm appearance: moderately echogenic soft tissue mass filling uterine cavity marked with small cystic spaces representing hydropic chorionic villi (grape-like)
uterus larger than dates, heterogeneous complex pattern, bilateral adnexal fullness, ovarian enlargement (theca lutein cysts)

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56
Q

Sonographic findings for partial mole:

A

placental tissue grossly enlarged and engorged with cystic spaces, embryo/embryonic tissue may be identified

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57
Q

Appearance of first trimester molar pregnancy may stimulate:

A

missed abortion, incomplete abortion, blighted ovum, hydropic degeneration of placenta associated with missed abortion

58
Q

Malignant forms of trophoblastic disease include:

A

invasive mole and choriocarcinoma

59
Q

When does invasive hydatidiform mole occur?

A

when hydropic villi of partial/complete mole invades uterine myometrium and at further penetrate uterine wall

60
Q

Clinically, invasive hydatidiform mole look like…

A

continued heavy bleeding, severe nausea/vomiting, very elevated hCG levels

61
Q

Sonographically, invasive hydatidiform appears….

A

enlarged uterus with multiple focal areas of grape-like structures throughout

62
Q

Can choriocarcinoma metastasize?

A

fast growing, commonly metastasizes to lungs, liver, brain

63
Q

Choriocarcinoma clinically appears:

A

vaginal bleeding, dyspnea, abdominal pain, neurologic symptoms

64
Q

What is the first conclusive sonographic sign of viability?

A

identifying IUP with/without cardiac activity

65
Q

When does the heart tube form?

A

between 3.5 and 5 weeks of conception

66
Q

What embryonic cardiac rates have a poor prognostic finding?

A

less than 90 bpm

and greater than 170 bpm (may lead to heart failure and fetal hydrops)

67
Q

What is the expected growth of the yolk sac?

A

.3mm/day

68
Q

What is the normal maximum diameter for the yolk sac?

A

5.5mm between 5 and 10 weeks gestation

69
Q

A yolk sac of what size has an increased risk for spontaneous pregnancy loss?

A

5.6mm or greater

70
Q

What is the double bleb sign?

A

simultaneous side by side appearance of amnion and yolk sac

71
Q

The mean amniotic sac diameter should be equal to…

A

the CRL

72
Q

Where is the embryonic disc located?

A

between the amnion and yolk sac

73
Q

When is the amnion best seen?

A

transvaginally between the fifth and seventh weeks of gestation

74
Q

When is the nuchal translucency the thickest?

A

at 11 to 14 weeks gestation

75
Q

An increased nuchal translucency can be found in…

A

trisomy 13,18,21, or fetuses with cardiac defects and other genetic syndromes

76
Q

What is the criteria for nuchal translucency measurements?

A

between 11 weeks and 13 weeks 6 days old, CRL must be between 45mm and 84mm, sonographer must obtain optimal mid-sagittal view, and embryo must be away from amniotic membrane with head in neutral position, no hyperextension or flexion

77
Q

What is one of the most common abnormalities seen sonographically in the first trimester?

A

cystic hygroma

78
Q

What specific chromosomal abnormalities does cystic hygroma associate with?

A

trisomies 13,18,21

79
Q

What is the most important marker in the first trimester for Turner’s Syndrome?

A

cystic hygroma

80
Q

Where does cystic hygroma appear?

A

posterior aspect of fetal neck and upper thorax

81
Q

Any posterior neck thickness greater than __, with or without septations, should be followed

A

3mm

82
Q

When can the embryonic head sonographically be seen?

A

7 weeks

83
Q

When does ossification of the cranium begin?

A

after 9 weeks

84
Q

What are the dominant structures seen within the embryonic cranium in the first trimester?

A

choroid plexus, which fills lateral ventricles that in turn fill cranial vault

85
Q

What does the brain look like at 7-8 weeks gestation?

A

cystic

86
Q

What is visualized in the brain at 12-13 weeks gestation?

A

falx cerebral, lateral ventricles with choroid plexus

87
Q

What is acrania?

A

partial or complete absence of cranium

88
Q

What is acrania a predecessor of?

A

anencephaly

89
Q

When acrania occurs, what happens to the fetal head?

A

has abnormally shaped head, referred to as “Mickey Mouse” head

90
Q

What is anencephaly?

A

congenital absence of brain and cranial vault

91
Q

What does anencephaly look like?

A

cerebral hemispheres either missing or reduced to small sizes; frog appearance (bulging eyes with nothing above)

92
Q

What is cephalocele?

A

midline cranial defect in which there is herniation of the brain and meninges

93
Q

What regions of the head does cephalocele involve?

A

occipital, frontal, parietal, orbital, nasal, or nasopharyngeal

94
Q

In what areas of the world is cephalocele more common?

A

in the western hemisphere, occipital defects are more common; in eastern hemisphere, frontal defects are more common

95
Q

What is iniencephaly?

A

rare, lethal anomaly of cranial development whose primary abnormalities include: defect in involving foramen magnum, retroflexion of spine where fetus looks upward with occipital cranium directed toward lumbar spine, open spinal defects

96
Q

What is ventriculomegaly and when is it seen?

A

dilation of vetricular system without enlargement of cranium; after 11 weeks

97
Q

What does ventriculomegaly look like sonographically?

A

choroid plexus shown to be dangling in dilated dependent lateral ventricle, compression and thinning of choroid plexus

98
Q

What is holoprosencephaly?

A

malformation sequence that results from failure of prosencephalon to differentiate into cerebral hemispheres and lateral ventricles between 4th and 8th gestational weeks

99
Q

What facial defects are associated with holoprosencephaly?

A

one eye, smaller distance between eyes, protruding trunk like tissue on face

100
Q

What three types is holoprosencephaly divided into?

A

alobar, semilobar, and lobar

101
Q

What type of holoprosencephaly is the most serious?

A

alobar consisting of single ventricle, small cerebrum, fused thalami, agenesis of corpus callosum, falx cerebri

102
Q

When does spina bifida occur?

A

when there is a failure of neural tube to close after 6 weeks gestation

103
Q

Sonographic apperance of spina bifida include:

A

lemon sign, banana sign, bulging within posterior contour of fetal spine and extrusion of the mass of vertebral column.

104
Q

Any gut herniation greater than __ should be considered suspcious and be followed for resolution after 11 weeks 5 days

A

6mm

105
Q

When does the bladder become sonographically visable?

A

at 10 to 12 weeks gestation

106
Q

What results in a very large bladder?

A

obstructive uropathy, especially at the level of urethra

107
Q

What is the most common ovarian mass seen in first trimester pregnancy?

A

corpus luteum cyst

108
Q

What hormone do corpus luteum cysts secrete?

A

progesterone

109
Q

What does a typical corpus luteum cyst look like?

A

measures less than 5cm in diameter and does not contain any septations

110
Q

Occationally, what does a corpus luteum cyst look like?

A

large, size greater than 10cm, internal septations and echogenic debris, color Doppler with ring of vascularity around it

111
Q

As corpus luteums regress, at what age should they not be seen anymore?

A

16 to 18 weeks gestation

112
Q

What does a hemorrhagic corpus luteum cyst look like>

A

fishnet septations, debris

113
Q

Due to ____ ___, fibroids may increase in size throughout first trimester and early in second trimester.

A

estrogen stimulation

114
Q

Rapid increase in fibroid size can cause what?

A

leads to necrosis and may cause significant pain

115
Q

What can a growing fibroid do to a gestational sac?

A

compress it and cause spontaneous abortion

116
Q

What do fibroids look like sonographically?

A

hypoechoic, echogenic, or isoechoic, poor acoustic attenuation, displacement of endometrium or uterus or both

117
Q

How do you differentiate between a gestational sac and a pseudogestational sac?

A

a pseudogestational sac has no living embryo/yolk sac, centrally located within the endometrial cavity, homogeneous level echoes

118
Q

The human chorionic gonadotropin (hCG) levels in gestational trophoblastic disease:

A

increase at a markedly higher rate than in a normal pregnancy

119
Q

The most common site of an ectopic pregnancy is:

A

the ampullary portion of the fallopian tube

120
Q

A fluid collection in the endometrium that stimulates the gestational sac of an early pregnancy is called:

A

pseudogestational sac

121
Q

Theca lutein cysts are:

A

the largest of the functional cysts, associated with trophoblastic disease or hyperstimulation of the hCG

122
Q

When the uterus empties itself of all products of conception, it is referred to as a(n):

A

complete abortion

123
Q

What is the approximate hCG level when a gestational sac is first observed (transabdominally)?

A

1800 mIU/mL

124
Q

All of the following statements regarding hydatidiform mole are true except:

a) a previous mole results in increased risk for recurrrence
b) it is associated with markedly elevated hCG levels
c) the sonographic appearance is similar to that of a degenerating myoma
d) although considered “tumors” of trophoblastic tissue, they are incapable of metastasizing

A

d) although considered “tumors” of trophoblastic tissue, they are incapable of metastasizing

125
Q

Higher than normal levels of hCG are seen in which of the following conditions?

a) multiple gestation
b) corpus luteum cyst
c) ectopic pregnancy
d) anembryonic gestation

A

a) multiple gestation

126
Q

Trophoblastic disease, which extends outside the uterus and spreads to the lungs or brain, is called:

A

choriocarcinoma

127
Q

Increased levels of hCG may cause:

A

theca lutein cysts

128
Q

In an early gestation, the gestational sac:

A

can be visualized transvaginally by 4wks and transabdominally by 6wks

129
Q

The placenta develops from:

A

the portion of the trophoblast attached to the myometrium, the decidua basalis

130
Q

During the first trimester, the developing embryo grows aproximately ___ every day.

A

1-2 mm

131
Q

A patient with a positive serum hCG test presents with some bleeding. The LMP indicates 5 to 6wks of gestation. Sonography does not reveal a fetal pole. The MOST likely diagnosis is a(n):

a) hydatidiform mole
b) complete spontaneous abortion
c) ectopic pregnancy
d) normal intrauterine gestation, but too early to detect the fetal pole

A

d) normal intrauterine gestation, but too early to detect the fetal pole

132
Q

In a patient with a complete spontaneous abortion, the MOST likely finding is a(n):

a) empty gestational sac with no evidence of decidua
b) embryo with no evidence of a heartbet
c) complex mass in the cul-de-sac
d) empty uterus with a decidual reaction

A

d) empty uterus with a decidual reaction

133
Q

A patient presents with a closed cervical os and a distorted gestational sac in the lower uterine segment. This MOST likely represents a(n):

a) blighted ovum
b) complete spontaneous abortion
c) threatened abortion
d) inevitable abortion

A

c) threatened abortion

134
Q

With respect to ectopic pregnancies, which of the following is TRUE?

a) an adnexal mass can usually be palpated
b) implantation in the interstitial portion of the tube is a common occurrence
c) cornual ectopic pregnancies may have dangerous prognoses
d) ectopic pregnancies cannot be carried past the first trimester

A

c) cornual ectopic pregnancies may have dangerous prognoses

135
Q

An embryo presents with an outpouching from the anterior abdominal wall into the base of the umbilical cord. This is MOST likely to be:

a) gastroschisis
b) omphalocele
c) normal herniation of the fetal gut
d) umbilical hernia

A

c) normal herniation of the fetal gut

136
Q

The type of twinning that occurs when two ova are fertilized is:

a) monozygotic twinning
b) dizygotic twinning
c) monochorionic and monoamniotic twinning
d) monochorionic and diamniotic twinning

A

b) dizygotic twinning

137
Q

What usually happens to the hCG levels in 48hrs in the presence of an ectopic pregnancy?

A

hCG levels rise at a subnormal rate

138
Q

A fluid collection in the endometrium that stimulates the gestational sac of an early pregnancy is called:

A

pseudogestational sac

139
Q

Which of the following is not a sonographic finding of a hydatidiform mole?

a) theca lutein cysts
b) grapelike clusters throughout the uterus
c) homogeneous uterine texture
d) low-impedance, high-flow Doppler pattern

A

c) homogeneous uterine texture

140
Q

The thin decidua overlying the portion of the gestational sac facing the endometrial cavity is the:

A

decidua vera

141
Q

The formula used to calculate gestational age from CRL is:

A

GA = CRL + 6.5

142
Q

What occurs when there is death of the embryo or fetus, but the gestational parts remain in utero?

A

incomplete or missed abortion

OB (10 decks)

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