FIRST TIMESTER COMPLICATIONS Flashcards
First trimester bleeding most common complication
Vaginal spotting
Frank bleeding
25% of patients
Pregnancy unlikely to progress if bleeding
Accompanied by severe pain
Uterine contractions
dilated cervix
Benefits from early TV examination
Carfully examine ,uterine cavity
Investigate of presence embryo
Fetal heart beat
Yolk sac
Retained products of conception
Placental hemáromas and subchorionic hemorrhage
Placental hematoma do not cause bleeding or spotting bcs it is in the chorionic sac without communication with endometrium
Most common occurrence of bleeding in first trimester
Subchorionic hemorrhage
Low pressure bleeding
Results from process of implantation of ovum into endometrial cavity and myometrium wall
Hematoma btw nyometrium and G sac
Clinical finding in sub chorionic hemorrhage
Bleeding
spotting
uterine cramping
If hemorrhage become large enough can lead spontaneous abortion
Distinguish subchorionic from abruption placenta
Occurs in second trimester abruption
Lucency posterior to the placenta retroplacental hemorrhage or abruption
Edge of the placenta subcharionic
Patient present with active vaginal bleeding
Sub chorionic bleeding is easily seen by
US adjacent o the G sac
Separation of the anterior placenta from uterine wall
Sub chorionic hemorrhage
Positive test no signal G SAC differential will be
Very early intrauterine pregnancy
Non developing pregnancy
Ectopic pregnancy
Absence of adnexal masses or free fluid
Grows of sac in first trimester for each day
1 mm/day
Normal embryo grows
At rate of 1mm/day
Yolk sac should be visualized TV when G SAC
Reaches 8 mm
Embryo should be seen when sac diameter
> 16 mm
If endometrium abnormal thick or irregularly echogenic different diagnosis
Intrauterine blood
Retained product of conception from incomplete abortion
Decidual reaction of ectopic pregnancy
Ar early intrauterine pregnancy
Incomplete spontaneous abortion US
From intact gestational sac with nonviable embryo to collapsed gestational sac grossly misshaped
Pregnancy failure when
The embryo is 7 mm or greater without heart beat
Or
MSD is 25 mm but no embryois visible
Spontaneous abortion
US of retained products may be subtle
Thickend endometrium>8mm
Increased vascularity of endometrium
Color Doppler strongly predictive bcs of throphablastic reaction
Presence of visible embryonic parts,g sac
Embryonic disc
Distinguish retained products of conception from blood clot
With color Doppler
clot= - No vascularity
Discriminating evidence for retained products
Quantitative hCG levels that da no decline normally
Thickened endlemétrium
Increased vascular flow
G sac without embryo or yolk sac 3possible conditions
Normal early intrauterine pregnancy <5werk)
Abnormal intrauterine pregnancy
Pseduogesiational sac in ectopic pregnancy
Criteria for abnormal gestational sac
Should be imaged TV or TA us when mean diameter is 5 mm
Correspond of age of 4 to 5 weeks
Interval growth of 1 mm per day
Lack means abnormal sac
Typical appearance of blighted or an . embryonic pregnancy is
Large
Empty
Gestational sac
Do not demonstrate York sac amnion embryo
MSD increase 1.1 mm per day but abnormal only 0.7 mm per day
US finding of G sac with abnormal intrauterine pregnancy
Embryo
Yolk sac amnion
Large G sac
Position
Shape
Throphoblastic reaction
Growth
MSG level
Abnormal embryo
Absence of cardiacmation in embryo 5mm or larger
Absence of cardiac motion after 6.5 mensiral weeks
Abnormal sac position
Cornual
Low
Hour glassing through cervical os
Abnormal throphoblasti c reaction
Absence of decidual sac
Thin trophoblastic reaction <2mm
Intra trophoblastic venous flow
Gestational trophoblastic disease
Prolifrative disease from benign form to malignant form from hydatiform (partial, complete or coexisíani
Mole
To invasive mole or choriocarcinoma
Coexistent molar pregnancy
Molar with normal intrauterine pregnancy
The first and most common of coexistent molar pregnancy
Twin pregnancy with normal fetus and normal placenta and complete mole
Second type of coexistent molar
Twin pregnancy with normal fetus am places an partial mole
The third and most uncommon type of coexistent
Singleton normal fetus with partial mole
Clinical landmark of trophoblastic disease
Is vaginal bleeding in first or early
Second trimester
Beía_hcg dramatically elevated > 100000
Hypermesis gravidarum or preeclampsia
AFT maternal notably low by complete mole
U S characteristic appearance of mole
Snow storm
Moderate echogenic soft tissue mass filling the uterus
Marked with small cystic spaces representing
Hydropic chorionic villi
Uterus filled with tiny grapelike clusters of tissue
Appearance of first trimester molar may simulate
Missed abortion
Incomplete abortion
Blighted ovum
Hydropic degeneration of placenta
Sonographic examination of thophoblastic disease
Uterine larger than date
Filled with heterogenous complex
Bilateral adnexal fullness
Ovarian enlargement of theta Lutron cyst
Partial mole appearance in US
Has identifiable placenta
Placenta enlarged with cystic spaces
Embryo arembryo tissue may seen
Often embryo abnormal and aborted in first trimester triploidy 69chromosome
Clinically symptoms in trophoblastic disease
Heavy bleeding
Very elevated hCG
Enlarged uterus with multiple focal areas of grapelikesters
in TV living embryo detects by
46 menstrual days
Cardiac rate less than … have poor prognosis
< 90 bpm away gestational age within first trimester
Tachicardia
> 170 bpm
Lead to heart failure
hydros
Pleural effusion
Pericardial effusion
Ascities
Oligohydrammous firsítrimesíer
G Sac 5 mm less tha CRL
Chromosomal abnormality with embryonic growth restriction and embryonic Oligohydramnios
Such as triploidy
Expected yolk sac growth
Maxima diameter of 0.3 mm/ day
Enlarged Yolk sac
5.6 mm or greater increased risk for spontaneous pregnancy loss.
Amnion best visualized with
… Td. Btw Month
Trans vaginal
5 to 7 weeks
Double bleb sign
Amnion and yolk sac in us
Simultaneous sis de by
Side the yolusac appearance
Amnion should appear as thinner of the two concentric structures
Embryonic lies btw amnion , , and yolk sac
How does look like abnormal amnion
Amnion becomes very easy to see
Thickness “echogenicity approach to yolk sac
Mean amniotic sac
Equal -to crown rump length
Anembryonic or failed pregnancy if
Mean sac diameter
>25 mm without embryo
One of the most emergent diagnoses with US
Ectopic pregnancy
Ectopic pregnancy
Pregnancy located outside central or fundal location of uterus
Clinical finding in ectopic pregnancy
Vaginial bleeding
empty uterus
Adnexal mass
Positive pregnancy test
May lead to hysterectomy or death ectopic pregnancy
Interstitialportion of tanupian tube near uterine Cornu
Massive hemorrhage
Level of hCG in ectopic pregnancy
Discriminatory levels met or surpass and no intrauterine sac seen ectopic should be suspected
Not at levels of normal pregnancy
HCG levels double every 3.5 days
90% ectopic not viable
Falling hCG levels indicate
Missed or incomplete abortion
US in. ectopic pregnancy
As manyas 20% of patients with ectopic pregnancy demonstrate intrauterine pseudo gestational sac
Pseudosac
Fluid collection aften blood in endometrium cavity
Decidualcysis
EMS thinner in EP compared to normal IUP and spontaneous abortion
BCS of lower bhcg LEVELS
Ring like cystic mass.
Do not contain either living embryo or yolk sac
Central located within endometria’s cavity
, G SAC eccentrically placed
Homogenous echoes in psedosaC
Presence of yolk sac indicates intrauterine
Most specific for ectopic in adnexa
Live embryo
Free fluid in adnexa
Extra. Uterine gestational sac thickened echogenic ring
Separate from ovary which represent trophoblastic tissue or chorionic vili
Color flow in ectopic pregnancy
Color flow shows RI <0.4 low resistance
Adnexal mass with ectopic pregnancy
Usually within fallopian tube
Hemato salpinx
Broad ligament
Complex adnexal mass aside from
Ectopic represent
Hematoma within peritonealcavity
Usually within fallopian tube hemãnosalpinx
Increased risk of ectopic.with
Moderate to large amount of free fluid in intraperitoneal space
Adnexal mass
Echogenic Free fluid 92% risk ectopic
Most life threatening of all ectopic
Intersristial pregnancy or cornual
In segment of Fallopian tube that enters uterus
Parauterine and myometrial vasculature - hemorrhage
US of interstitial pregnancy
Ecentric placed G SAC
Incomplete MYOMETRIAL mantle surrounding sac
Cervical pregnancy
Î riskof complete hysterectomy BCS of uncontrollable bleeding
Embryonic Abnormalities in the first trimester
- Nuchal translucency
2.cardiac anomalies
3.cranial “ - Abdominal wall defects
5.Obstetric uropathy
Nuchal translucency
Maximum thickness of subcutaneous lucency ‘ at back of neck 11-14 weeks
Î Nuchal translucency with
Trisomy,13,18,21
Cardiac defects
Genetic syndromes
To assess risk for aneuploidy
NT combined with biochemical markers
Beta hCG
PAPPA
Condition for NT measurement
Btw 11weeks and 13 weeks and 6 days
CRL BTW 45mm and 84mm
Mid sagittaL plane
Away from amniotic membrane
Neutral head position
No flexion a extension
Hind brain
Cerebellum
Medulla ablongata
Pons
By FMF
First trimester fetus check for
Nuchal translucency
Abnormalities of hind Brain
Nasal bone
Tricuspid regurgitation
Flow in ductus venousus
markers for cardiac
defects
incread nuchal Translucency
Tricuspid Regurgitation
Reversal of flow in ductus Venus
Ectopic cordis and
limb wall Complex
Four-chamberview and great vessels out flow 12 weeks
Dominant structure
Seen within
embryonic in
cranium
first Trimesier
choroid plexus wich fills lateral
venitricle that in turn fill cranial vault
Acrania
Partial or complete absence of cranium
Predecessor of anencephaly
Ossification of cranium begins
After 9 weeks
Biparietal diameter
Acrania cause identified as early as
12 weeks
Micky mouse head
In acrania head shap
ALP level increase
Ammniotic bands possible reason
Anencephaly
Absence of brain and cranial vault
Cerebra al hemispheres either missing or reduced to small masses
Near end of first trimester
Absence of the cranium superior to the orbits
Base of skull is present
Brain may see as it projects from open cranial vault
Facial features
Cephalocele
Midline cranial defect
There is herniation of the brain and meninges
Cephalócele in western and eastern hemisphere
Western_occipital defect
Eastern_ frontal defect
Cephancel may involve
Occipital
Frontal
Parietal
Orbital
Nasal
Nasopharyngeal
Cranial cephalócele in US
Enlarged cisternal magna
Enlarged third ventricle
Absent brain tissue
Iniencephaly
Rare lethal
Anomaly
Of cranial development
Defect in occiput involving foreman magnum
Retroflexion of spine fetus looks upward
Open spinal defects
Ventriculomegally or
dilation of ventricular system Without enlargement cranium after il weeks
Ventriculamegaly in us
Choroid plexus dangling in dilated dependent lateral ventricle
Holoprosensephaly
Failure of prosencephalon to differentiate into cerebral hemispheres and lateral ventricles and thalamus btw 4-8 weeks
Variable degrees of facial dimorphism
Butterfly sign , is absent single ventricle is present on the biparieral diameter plane
Most serious type of holoprosencephaly
Alobar single ventricle small cerebrum fused thalami genesis
Of corpus canosum and falx cerebry
Before 9 weeks normal fetal brain has. Ventricle
Single ventricle until fa lx
Cerebri develops after 9 weeks
Dandy _walker
Cystic dilation of 4 ventricle
Complet or partial genesis of cerebral vermis
Hydrocephay
6-7 -weeks
US of dandy
Large posterior _ fossa cyst
Continuous with a ventricle
Absent of cerebellum vermis
Dilated third and lateral ventricles
Spina bifida
Failure of neural tube to close after 6 weeks
US of spina bifida
Spinal irregularities
Bulging within posterior fetal spine
Extrusion of the mass from vertebral column
Cranial signs
Leman sign
Banana sign
Closer to 12 weeks
Normal bowel herniation
Btw 8-12 week
As an echogenic mass
At the base of the umbrical Cord
Abdominal was defects types
‘emphalócele
gastroschisis
Limb-body
Complex
Midgut herniation
Normal gut herniarien measure
6 - 9 mm a t8 weeks
5-6 mm at 9 weeks
Gut herniation >6 mm abnormal
Feral bladder formation
10 _12 weeks
Obstructive urophathy
At the he level of urethra results in very large bladder
Extended from pelvic to abdomen
Cystic mass
Bladder extrophy
Key hole sign
Obstructed urethra
In connection of bladder and ureathra
One of the most common abnormalities seen in us in first trimester
Cystic hygroma
Chromosomalabnormalitis
Sonolucent cystic hygroma with nuchal thickening
If cystic hygroma detected in second or third trimester
Turner’s syndrome is most common karyotype
Differentiation btw cystic hygroma with
Nuchal thickening
Encephalócele
Cervical meningomyelocele
Teratoma
Hemangioma
Umbria cord cysts
Not persist throughout second trimester
Umbrical cord cysts differential
Amniotic cysts
Emphalomesantric duct cysts
Allantoic cysts
Vascular anomalies
neoplasm
Whavion’s jelly abnormalities
Most common ovarian mass in first trimester
Corpus lutem cyst
Typical corpus luteum cyst. Cm
<5 Cm in diameter
Does not contain separations
Corpus lutem abnormal cyst
Large more than 10 Cm
Internal separations echogenic debris
BCS of internal hemorrhage
Color flow ring of increased vascularity
Corpus lutem cyst may mistaken with
Hemato salpinx
Distal tubal ectopic pregnancy
Ovarian ectopic pregnancy
Ovarian neoplasm
Fishnet pattern
Reticular pattern
Fibrin strands
Uterin mass
Leiomyomas
Fibroids
Relationship to placenta and cervix
• Sometimes difficult to distinguish retained products of conception from blood clots
• Sometimes difficult to distinguish retained products of conception from blood clots Novascu
Quantitative hCG levels that do not decline normally, thickened endometrium, and increased vascular flow will be discriminating evidence for retained products.
Spontaneous Abortion
This patient had been diagnosed with spontaneou
miscarriage 3 weeks before this examination.
Patient had bled and passed tissue.
Sagittal and coronal images of the uterus show highly vascularized endometrial contents, consistent with retained products of conception.
Theca lutein cysts.
Transvaginal grayscale image of the pelvis demonsti simple bilateral ovarian cysts in this patient with a hy
mole. A pocket of free fluid is present between the two ovaries
tational Trophoblastic Disease
• Malignant forms of trophoblastic disease includ invasive mole and choriocarcinoma.
• Invasive hydatidiform mole occurs when villi of partial or complete mole invades myometrium and may further penetrate wall.
Gestational Trophoblastic Disease
• Choriocarcinoma malignant form of trophoblastic disease that occurs in 2% to 3% of molar pregnancies.
• Tumor fast growing; commonly metastasizes to lungs, liver, brain
• Clinical symptoms include vaginal bleeding in addition to dyspnea, abdominal pain, and neurologic symptoms, depending on where metastasis spread.
91 Embryonic Oligohydramnios and
Growth Restriction
9) Embryonic Oligohydramnios and
Growth Restriction
• Embryonic growth restriction can be determined only by relative sonographic dating, either by reliable menstrual history or by growth delay of embryo or gestational sac in relation to serial sonograms.
• Chromosome abnormalities, such as triploidy, have been associated with embryonic growth restriction and embryonic oligohydramnios.
Embryonic Yolk Sac Evaluation
• Expected yolk sac growth 0.3 mm/day
• Normal yolk sac has maximal diameter of 5.5 mm between 5- and 10-weeks gestation.
• Enlarged yolk sac, 5.6 mm or greater, has increased risk for spontaneous pregnancy loss.
Ectopic Pregnancy
• Associated risk factors:
• Rise in incidence of pelvic infections
• Use of intrauterine contraceptive devices
• Fallopian tube surgeries
• Infertility treatments
• History of ectopic pregnancy
Ectopic Pregnancy
• Using transvaginal techniques, hG discriminatory level in detecting IUP has been shown to be:
• 800 to 1000 IU/L based on 215
• 1000 to 2000 IU/L based on first IRP
Sonographic Findings in Ectopic
Pregnancy
A
B
A. Sagittal sonogram demonstrating high-velocity color flow in the left adnexa that surrounded the ectopic gestational sac. Other images demonstrated an empty uterus with normal endometrial canal.
B. Coronal sonogram demonstrating uterus (UT) and right ovary (Rt OV), with an echogenic concentric ring and embryo seen centrally with fetal heart motion consistent with ectopic pregnancy.
Arrows, Decidua/trophoblastic villi.
Endometrium
• Pseudosac-
- Fluid collection, often blood in endometrial cavity
- Occurs in up to 20%
• Decidual cysts
• Appearance and thickness of endometrium: not very useful
- EMS usually thinner in patients with EP compared to normal
IUP and spontaneous AB, because of lower B-HCG levels
Abortion
Copyright © 2012, 2006, 2001, 1995, 1989,
Sonographic Findings in Ectopic
Pregnancy
• Pseudogestational sacs do not contain either living embryo or yolk sac.
• Pseudogestational sacs centrally located within endometrial cavity, unlike burrowed gestational sac, which is eccentrically placed.
• Homogeneous level echoes commonly observed in pseudogestational sacs, unlike normal gestational sacs
• Presence of yolk sac positively indicates intrauterine gestation..
Sonographic Findings in Ectopic Pregnancy
• Examining adnexa sonographically is critical in evaluation of ectopic pregnancy.
Sonographic Findings in Ectol
Pregnancy one of most frequent findings of ectopic pregnancy
• Identification of extrauterine sac within adnexa one of most frequent findings of ectopic pregnancy
• Extrauterine gestational sacs often demonstrate thickened echogenic ring, separate from ovary, which represents trophoblastic tissue or chorionic villi and possibility that embryo or yolk sac will be seen.
Adnexal Mass with Ectopic
Pregnancy
• Risk of ectopic pregnancy can be greater than 90
• when intrauterine gestation absent and there is
• corresponding adnexal mass.
Complex adnexal masses, aside from extrauterint gestational sacs, often represent hematoma with peritoneal cavity.
• Usually contained within fallopian tube (hematosalpir or broad ligament
Adnexal Mass with Ectopic
Pregnancy
• Studies have correlated increased risk of ectopic pregnancy with:
• Moderate to large quantities of free intraperitoneal fluid
• Associated adnexal mass
Adnexal Mass with Ectopic
Pregnancy
• 92% risk of ectopic pregnancy with
echogenic free fluid reported, with 15% of cases demonstrating echogenic free fluid as only sonographic finding.
• When fluid present, sonographer should also look
• When fluid present, sonographer should also look at abdominal gutters and right and left upper quadrants to evaluate extent/volume of fluid present.
Cranial Anomalies
• Embryonic head
• Embryonic head can be sonographically identified
77 weeks.
C, Fetal profile of an anencephalic
fetus at 13-weeks.
The fetus is lying in a vertex position with the spine down. The face is pointing toward the anterior placenta; the skull is absent from the fetal forehead to the top of the cranium
Cranial Anomalies
• Holoprosencephaly is malformation
sequence tI results from failure of prosencephalon to differentiate into cerebral hemispheres and later ventricles between fourth and eighth gestational weeks.
• Anomaly ranges from complete to partial failure of cleavage of prosencephalon with variable degrees of facial dysmorphism. fused thalamus
Holoprosencephaly is divided into three typts: alobar, semilobar, and lobar.
Alobar most serious and consists of single ventricle, small cerebrum, fused thalami, agenesis of corpus callosum, and falx cerebri
imnartant to
Holoprosencephaly
(A) Ultrasonography of a normal fetus at 12 weeks of gestation shows the butterfly sign of the choroid plexus on the biparietal diameter plane.
(B) A fetus with holoprosencephaly at 13 weeks of gestation. The butterfly sien is absent, and a single ventricle is present on the biparietal diameter plane.
Cystic Hygroma
• Cystic hygroma and nuchal thickening may be concordant; differentiation may be difficult.
• Any posterior neck thickness >3 mm, with or without septations, should be followed.
• Differentiation between cystic hygroma, encephalocele, cervical meningomyelocele, teratoma, or hemangioma should be assessed.
Corpus Luteum Cyst
• Color flow imaging may
Corpus Luteum Cyst
• Color flow imaging may demonstrate ring of increased vascularity surrounding corpus luteum, displaying low-resistance (high-diastolic) waveforms on pulsed Doppler imaging.
• Such findings are similar to decidual flows characterized in ectopic pregnancies but are intraovarian in location
Corpus Luteum Cyst appeared
fishnet pattern
- patten
Reticular pattern
fibrin strands
