Assessing Normal And Abnormal Pregnancy From 4-10 Weeks

Assessing normal and abnormalpregnancy from 4-10 weeksMonique HaakISUOG’s basic training curriculum

Goals 4-10 week assessment by US Normal appearance gestational sac (GS), yolk sac (YS) andembryo Assessment of mean sac diameter (MSD) and CRL Viability criteria and terminology in non-viable pregnancy Recognition of ectopics, principles of pregnancy of unknownlocation (PUL) Role hCG and management of PUL Molar pregnancyISUOG’s basic training curriculum

Conception and implantationISUOG’s basic training curriculum

Embryo from 0-8 weeksISUOG’s basic training curriculumSource: The Virtual Human Embryo Project

Implantation- gestational sac1st evidence pregnancy on ultrasound; completely embedded blastocyst 14 d post conceptionISUOG’s basic training curriculum NEJM 2001;345/1400

Gestational sac Small, round fluid collection inside uterine cavityNormally positioned in mid-to upper uterine cavitySurrounded by a hyperechogenic rimVisible at approximately 4 weeks gestationBeware of difference in gestational age and embryoageISUOG’s basic training curriculum

Location of gestational sac within upper half of uterusISUOG’s basic training curriculum

04ISUOG’s basic training curriculumweeks - 2 mm

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Gestational sac measurement54w mean ø3.9mm64w mean ø18.8mmGestational sac diameterMean of 3 orthogonal planesGrowth in early pregnancy 1mm/dayISUOG’s basic training curriculum Knez et al Best practice Reseach Clin O & G 2014;28:621-36weeks

Yolk sac First structure identified within gestational sacConfirms intra uterine pregnancy, 100% PPVSpherical in shapeEchogenic peripherySonolucent centerAttaches to embryo by vitelline ductISUOG’s basic training curriculum

Yolk sac Imaged 5 - 5.5 wImaged when MSD 5-6 mmImaged 3-5 d prior to embryoDiameter peaks at 6 mm at 10 w, then decreasesUsually not visible after first trimesterNumber of yolk sacs usually equals number of amnionsISUOG’s basic training curriculum

Yolk sacISUOG’s basic training curriculum05 and47weeks

Yolk sac in multiple pregnancyDichorionic diamnioticISUOG’s basic training curriculumMonochorionic diamniotic Monochorionic monoamniotic

Amnion First seen 5.5 w – small membraneous structurecontinuous with the embryo Contains clear fluid Separates the embryo and amniotic space fromthe extraembryonic coelom Obliterates the coelomic cavity by 12-16 weeksISUOG’s basic training curriculum

93wAmnionAmnion73 w92 w

Heartbeat use M-mode55 w74 wHeartbeat visible form CRL 2-4 mmRapid frequency 5-9 weeksUse M-modeISUOG’s basic training curriculumWeeks

Crown Rump Length (CRL) ISUOG guidelineMidline sagittal section of whole fetusIdeal orientation horizontallyMagnification fill most of width of screenFetus in neutral positionAmniotic fluid between chin and chestEndpoints clearly definedISUOG’s basic training curriculum ISUOG guideline 1st trim us scan UOG 2013;41:102-113

Embryo 6-8 weeks64wISUOG’s basic training curriculum744w84w

94 weeksISUOG’s basic training curriculum

10 weeksISUOG’s basic training curriculum

Practical rules early pregnancyTransvaginal ultrasoundAbdominal ultrasoundGestational age MeasurementGestational age MeasurementGS402 mm5010 mmYS502 mm603 mmHeartbeat5470 bpm64110 bpmCRL533 mm636 mmMovement70CRL in cm 6,5 GA in weeksISUOG’s basic training curriculum70

Pain & blood loss in early pregnancyEventFrequencyPain & vaginal bleeding1:5 pregnant womenBlood loss50% continue into normal pregnancy50 % remaining blood lossNon viable, of which 10—15% ectopic pregnancyPain in early pregnancylate symptom!!Obstetric cause:Miscarriage, ectopic, haemorrhage ruptured corpus luteum cyst, ovarian torsionNon-obstetric cause:Cystitis, appendicitis, ureteric stones, constipationISUOG’s basic training curriculum Knez et al Best Practice Res Clin O & G 2014;28:621-636

Terminology early pregnancy events 1TerminologyCommentViableResults in liveborn babyNonviableCannot result in liveborn baby (failed intrauterinepregnancy, ectopic pregnancy)Intrauterine pregnancyuncertain viabilityTV ultrasound - intrauterine GS, no heartbeatEmpty sacGS: absent structures, minimal debris, no heartbeatHuman chorionic gonadotropin Positive serum pregnancy test serum hCG 5 IU/mLISUOG’s basic training curriculumDoubilet et al NEJM 2013;369:1443-51

Terminolgy early pregnancy events 2TerminologyUltrasound findingsFetal lossPrevious CRL and heartbeat followed by loss of heartbeatDelayed miscarriage/earlypregnancy lossUS intrauterine pregnancy: reproducible loss heartactivity, failure increase CRL over 1 w or persisting emptysac at 12 wEctopic pregnancy blood/urine hCG, gestational sac outside uterusHeterotopic pregnancyIntrauterine ectopic pregnancyPregnancy of unknownlocation (PUL)No identifiable pregnancy on US with blood/urine hCGISUOG’s basic training curriculumFarquharson et al Human Reproduction 2005;20:3008-3011

Guideline TV US intrauterine pregnancy failure and uncertain viabilityDiagnostic for pregnancy failureSuspiciousCRL 7 mm no heartbeatCRL 7mm no heartbeatMean GS ø 25 mm no embryoMean GS ø 16-24 mm no embryoAbsence embryo with heartbeat 2 wk afterscan GS without YSAbsence embryo with heartbeat 7-13days after scanGS without YSAbsence embryo with heartbeat 11 daysafter scan GS with YSAbsence embryo with heartbeat 7-10 days after scan GSwith YS/ not diagnostic pregnancy failureAbsence embryo 6 wks after LMPIf viability in doubt rescan after 1 week Empty amnion adjacent to YS no embryoEnlarged YS 7mmISUOG’s 43-51Small GS in relation to size of embryo ( 5 mmdifference between mean GS ø and CRL

Early pregnancy: VitalityNormalISUOG’s basic training curriculumAbnormal

Uncertain viabilityGS and YS, no heartbeatRepeat scan 1 week26 weeks

Gestational sac: failing pregnancyISUOG’s basic training curriculum

Twin pregnancy with vanishing twin7w11w24 mmISUOG’s basic training curriculumEvron et al Fertil Steril 2015;103:1209-14

HaematomaISUOG’s basic training curriculum

Miscarriage8 weeks no heartbeatISUOG’s basic training curriculum

Ectopic pregnancyISUOG’s basic training curriculum

Early pregnancy: normal values of hCGhCG (intact 05000003456789weeks1012141618

Early pregnancy: normal values of hCGhCG (intact ß-subunits)250000200000150000P95IE/LGestational sac visible at 1800 MIU/mlmedianP510000050000hCG (intact 0P95medianP51500100050003ISUOG’s basic training curriculum4weeks56

Ectopic right fallopian tubeLMP 8 weeksISUOG’s basic training curriculum

Interstitial pregnancyISUOG’s basic training curriculum

Ectopic managementDay 151wDay 353wAbdominal painminimal bloodlossEmpty uterusL and R ovary normalhCG 1349 IU/LEmpty uterusNext to L ovary ectopicmass 3.4 x 1.4 cmhCG 1890IU/LISUOG’s basic training curriculumReturn in 2 days

Cervical ectopic pregnancyGestational sac in lower segment in cervical canalISUOG’s basic training curriculum

Gestational sac in lower segment - in cs scarISUOG’s basic training curriculum

Heterotopic pregnancyPrevalence heterotopic pregnancySpontaneous pregnancy1:30,000ART pregnancy1:100-500IntrauterineEctopicISUOG’s basic training curriculum Maruotti & Russo Fert Ster 2010;94:e49

Management Protocol – Pregnancy Unknown Location (PUL)Progesterone(nmol/L)ß-hCG(IU/L)Likely diagnosisManagement 20 25Spontaneous resolving pregnancyCheck urine or serum ßhCG in 7 days20-60 25Unviable or ectopic pregnancy with Check serum ß-hCG in 2moderate risk requiringdaysintervention 60 1500Normal intrauterine pregnancyRepeat scan when ßhCG expected 1000 60 1500Ectopic pregnancy with high riskrequiring interventionRepeat scan same dayby senior examinerISUOG’s basic training curriculumDay et al UOG 2009;33:704-710

Hydatiforme moleISUOG’s basic training curriculum

Hydatiforme mole84w15 wHCG 330.000IU/LCompletePrevalence 1:1500-200046, XX only paternalPersisting throphoblast 15%ISUOG’s basic training curriculumPartialPrevalence 1:70069 XXX of 69 XXY (triploïdy), paternal and maternal2%

Hydatiforme mole in twin pregnancy Blood loss and abdominal pain 8 weeksUS dichorionic twin pregnancy of which 1 molahCG 439.467 IU/lCounseling: miscarriage, hypertension, preeclampsia, thyroid disease,persistent trophoblast disease, lung metastasesPrevalence 1:10000-100.000ISUOG’s basic training curriculum

Accuracy of US diagnosisHistology:CHMPHMAccuracy US95%20%Histology:non molar failed pregnancyISUOG’s basic training curriculumKirk et al UOG2007;29:70-75

Conclusion Aware of normal appearance and assessment GS, YS & embryofrom 4 weeks gestational age onwards Criteria and terminology of viable and nonviable pregnancy In doubt about viable intrauterine pregnancy: repeat scan 1 w Scan uterus and ovaries to recognize ectopics Management of PUL and role hCG and progesteron Molar pregnancy appearance and pitfalls In doubt of location of pregnancy: repeat scan within 2 daysISUOG’s basic training curriculum

Complete MOLAPartiele MOLA Karyotype: 46, XX (85%) or 46 XY (15%): allchromosomes are paternal. Karyotype 69, XXX or 69, XXY: Two sperm either 23, Xor 23, Y fertilized the ovum leading to triploidy (C)(chomosomen zijn zowel paternaal als maternaal). Mechanism: Androgenesis: 23, X sperm fertilizesan egg that is maternal inactivated, meaningthat the egg has no active maternalchromosomes or an empty egg ( no maternalchromosomes). The egg upon fertilization,duplicates the paternal chromosomes leading to46, XX (A). hydropische zwelling van een gedeelte van de vlokken;embryonale structuren kunnen aanwezig zijn. 1: 20 000 zwangerschappenPersisteren 2% In regards to 46, XY moles, the maternal inactiveegg is fertilization by two sperm with onecarrying the X and the other carrying the Y gene(B). Hydropische zwelling van alle vlokken;geen embryonale structuren. 1:2000 zwangerschappenISUOG’sbasic training Persisteren15% curriculum

US intrauterine pregnancy: reproducible loss heart activity, failure increase CRL over 1 w or persisting empty sac at 12 w Ectopic pregnancy blood/urine hCG, gestational sac outside uterus Heterotopic pregnancy Intrauterine ectopic pregnancy Pregnancy of unknown location (PUL) No identifiable pregnancy on US with blood/urine hCG