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Early pregnancy ultrasonographic evaluation

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Early pregnancy ultrasonographic evaluation

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Early pregnancy ultrasonographic evaluation

  1. 1. Early Pregnancy Ultrasound PPrreesseenntteedd bbyy DDrr// AAhhmmeedd WWaalliidd AAnnwwaarr AAssssiissttaanntt pprrooffeessssoorr ooff OObbss && GGyynn BBeennhhaa FFaaccuullttyy ooff MMeeddiicciinnee EEggyypptt 22001144
  2. 2. OBJECTIVES Ultrasonographic evaluation of early pregnancy and its complications
  3. 3. Early Pregnancy Ultrasound report NORMAL ABNORMAL  Location  Structure  Viability  Dating  Number •Assessment of other pelvic masses ???? •Screening for fetal abnormalities ???? •Assisting CVS and amniocentesis????
  4. 4. Structure & Viability
  5. 5. Structures of 1st Trimester Pregnancy  Gestational sac  Yolk sac  Embryo/fetus  Presence of cardiac activity
  6. 6. Gestational sac Visible at 4-5wks GA with TVUS & at 6 wks GA with TAUS. Eccentric echogenic ring with anechoic center . Measure by Mean Sac Diameter. GS size increases by about 1mm/day in early pregnancy Discriminatory zone: serum hCG level in which GS is expected to be visible by US : hCG >2000 mIU/ml by TVUS& hCG >6000 mIU/ml by TAUS
  7. 7. Structures of 1st Trimester Pregnancy  Yolk sac: : bright ring with anechoic center located inside GS seen at 5wk GA & persists to 11-12 weeks.  Embryo/fetus: seen by TVUS as thickening of yolk at 6wks GA.  Presence of cardiac activity: usually seen around the time fetal pole is present, further confirming viability (6th wks) Yolk sac Fetal pole
  8. 8. Confirming intrauterine gestation
  9. 9. Confirming intrauterine gestation 1) Double decidual sac sign 2) Intradecidual 3) Double bleb sign sign
  10. 10. Dating
  11. 11. 12 10/28/14 Early ddaattiinngg ooff pprreeggnnaannccyy  5 – 9 weeks : use of mean GS diameter  6 – 12 weeks : use of CRL (most accurate dating of early pregnancy)  After 12 weeks : use of BPD
  12. 12. Formulas to Calculate gestational age  MGSD (mm) + 30 = gestational age (days) (between 5 and 9 weeks)  CRL (mm) + 42 = gestational age (days) (between 6 and 12weeks)
  13. 13. Diagnosis ooff mmuullttiippllee pprreeggnnaannccyy
  14. 14. TTyyppeess ooff mmuullttiippllee pprreeggnnaannccyy
  15. 15. Twin peak (or Lambda sign) pathognomonic for dichorionic placentation T-sign pathognomonic for monochorionic placentation
  16. 16. Other roles of US  Confirm fetal number .  Confirm viability.  Diagnosis of vanishing twin syndrome.  Exclude any malformation or conjoined twins (especially at age > 35y = genetic amniocentesis)  Needed with other procedures  CVS  fetal reduction
  17. 17. Abnormal early (first trimester) pregnancy
  18. 18. Abnormal early (first trimester) pregnancy  FFaaiilleedd eeaarrllyy pprreeggnnaannccyy..  Pregnancy of uncertain viability (i.e. IU pregnancy in a situation with no enough criteria (usually on ultrasound grounds) to confidently categorize a pregnancy as a miscarriage).  Pregnancy of unknown location.  Ectopic pregnancy  Trophoblastic disease  Subchrionic hemorrhage  Incomplete abortion (retained products of conception)
  19. 19. FFaaiilleedd eeaarrllyy pprreeggnnaannccyy && Pregnancy of uncertain viability
  20. 20. Failed early pregnancy (FEP( Pregnancy of uncertain viability (PUV( NNoo ccaarrddiiaacc aaccttiivviittyy wwiitthh CCRRLL ≥≥77mmmm < 6mm No fetal pole with MSD > 25 mm (Anembryonic Pregnancy) < 20mm Others Absence or inadequate growth on serial scans at least 7-10 days Mean GSD < 25mm and containing yolk sac only Management Termination Follow up US in 7-14 days with serial beta HCG correlation… viable or nonviable. TVUS criteria of : Doubilet et al., N Engl J Med. 2013 Oct 10;369(15):1443-51
  21. 21. US poor prognostic indicators of pregnancy include:  No yolk sac, where: MSD > 8 mm embryo seen  Irregular gestational sac  Low position of the gestational sac Doubilet et al., N Engl J Med. 2013 Oct 10;369(15):1443-51
  22. 22. Anembryonic Pregnancy
  23. 23. Pregnancy of unknown location
  24. 24. Pregnancy of unknown location (PUL)  PUL = +ve pregnancy test + no IU or Ext.U pregnancy in US scan ↓↓↓↓↓ Differential diagnosis is: 1. very early pregnancy, not detected with ultrasound 2. complete miscarriage 3. unidentified ectopic pregnancy
  25. 25. Ectopic Pregnancy
  26. 26. True vs. pseudo-gestational sac
  27. 27. True GS (DDSS) Fluid collection (or sac) shows a small “beak sign” that connects with or points toward the uterine cavity line
  28. 28. HETEROTOPIC PREGNANCY
  29. 29. Yolk sac Fetal pole
  30. 30. Other types of ectopic pregnancy
  31. 31. Cer vical ectopic pregnancy  GS within the cervix .  Abnormally low sac position.  Colour Doppler : hypervascular trophoblastic ring in the cervical region .
  32. 32. Interstitial ectopic pregnancy  Eccentric gestational sac: the diagnosis is suggested by visualisation of an intrauterine gestational sac or decidual reaction located high in the fundus, that is surrounded by less than 5 mm of myometrium in all planes.  Interstitial line sign : an echogenic line from the mass to the endometrial echo .
  33. 33. Sonographic features of Caesarean scar ectopic pregnancy (CSEP)  empty uterus  empty cervical canal  GS in the anterior part of the lower uterine segment  absence of myometrium between the bladder wall and the GS
  34. 34. Molar Pregnancy
  35. 35. Molar pregnancy ( Snow storm+ Theca-lutein cysts )
  36. 36. Subchorionic Hemorrhage
  37. 37. Retained products of conception (incomplete abortion)
  38. 38. Thickened Nuchal Tanslucency (NT):  Used for screening (SS) for Down’s syndrome in first trimester  Serial screening: Pregnancy associated plasma protein levels, hCG levels, NT thickness  Measured during 11-14 wks gestational age  Seen on sagittal image as increased subcutaneous non-septated fluid in posterior fetal neck  Measurement >3mm usually considered abnormal, however exact cut off measurements are dependent on maternal age/gestational age  Detection rate of screening for Down’s Syndrome in first trimester:  sequential screening with NT: 82-87%  NT alone: 64-70%
  39. 39. Safety of ultrasound in pregnancy  General perception is that ultrasound is safe (It is not ionising radiation)  However, bioeffects can be either thermal or mechanical (i.e. cavitations) with high power ultrasound  One RCT of repeated routine ultrasound with Dopplers in the 3rd trimester found a small but significant decrease in birth weight in the exposed cohort  A meta analysis showed males exposed to ultrasound in uterus are more likely to be left-handed
  40. 40. How to reduce biohazards ALARA As Low As Reasonably Achievable ALARA principle:  Lowest acoustic power  Shortest duration  Least exposure to sensitive target tissues
  41. 41. Take home message  Ultrasound is no substitute for a good history  ALWAYS do an abdominal scan with ( Full bladder) before using the vaginal probe with ( Empty bladder)  You will always be better than sonographers because you know the anatomy and pathology  Avoid premature conclusions
  42. 42. Take home message  Systematic scan should be performed  US scans are useful to be combined with HCG tests before decision.  With ultrasound , an early intervention or conservative management in pregnancy can be determined.  General perception is that ultrasound scan is safe in pregnancy.
  43. 43. E.mail:::ahwalid2004@yahoo.com

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