First Trimester
Complications
Fetal Biometry Workshop
Day 1
Objectives
Review presentation , consequences &
sonographic findings of ectopic pregnancy
Discuss different types of abortion
Define Blighted Ovum
Review different types of molar pregnancy
Identify coexisting maternal pelvic masses
Tubal Implantation
Abnormal tubes
Congenital
PID***
Tubal Surgery
Normal tubes
Transmigration of ovum
Embryonic abnormalities
Hormonal imbalance
Pelvic masses
IUD
Reduced tubal motility
Tubal Implantation
Hormonal Imbalance
Estrogen
Progesterone
Tubal Implantation
Mechanical
Developmental
anomalies
Infectious damage
Tubal surgery
Cervical Implantation
Below level of
internal os
Endometrium
unsuitable
Endometritis
IUD
Rapid transit
Interstitial Implantation
Abdominal Implantation
Primary
Normal tubes &
ovaries
Secondary
Tubal abortion with
extension into
peritoneal surface
Ovarian Implantation
Rare <0.52%
Gestational sac occupy ovary position
Gestational sac connected to uterus by
uteroovarian ligament
Ovarian tissue in wall of sac
Failure of ovum to leave follicle
Tubal abortion implants on ovarian surface
Clinical Presentation
Vaginal spotting or
bleeding
Abdominal pain
Amenorrhea
Adnexal tenderness
Palpable adnexal mass
+ Pregnancy test
hCG
Lower levels in ectopic
Rapid decrease
Hydatidiform mole
Nonviable pregnancy
Serum amylase
Ruptured tubal
pregnancy
Sonographic Protocol
Normal uterine pregnancy
GS – 4 to 5 weeks after LMP
Uterine Image with Ectopic
Decidual cyst
3 mm cyst (arrow) is
identified within the
decidua.
Cyst is not an
intradecidual
gestational sac
Peripherally located
within the decidua
Does not abut the
endometrial canal
Coronal View
Right Adnexa
Fallopian tube filled
with fluid [blood]
Trophoblastic ring
(arrow)
Echo-free fluid
surrounds the tube
Doppler
high-velocity
low-resistance flow
Sonographic Protocol
Unruptured tubal pregnancy
Salpingotomy
Sonographic Protocol
Ruptured tubal pregnancy
Sonographic Protocol
Chronic tubal pregnancy
Blood + trophoblastic tissue + disrupted tubal
tissue + inflammatory response = pelvic
hematocele
Indefinite uterus sign – echogenicity similar
to uterus
Mimics endometriosis and PID
Treatment Options
Surgical intervention
Laparoscopy or laparotomy
Salpinectomy
Hysterectomy
D&C
Non-Surgical intervention
Administer Methotrexate
Culdocentesis
Treatment Options
Wait & See Approach
Decreasing hCG
No evidence of intrauterine pregnancy
No fetal heartbeat
No sign of bleeding or tubal rupture
Case Study
Sagittal transvaginal uterine scan
Case Study
Transvaginal scan of the right adnexa
Case Study
Sagittal view of the right adnexa
Case Study
Power Doppler Right Adnexa
Sonographic Differential
Ectopic Location
Differential Diagnosis
Tubal

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Corpus Luteum cyst
Adnexal mass
Ahesed bowel
Acute appendicitis
Ovarian

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
Tubal ectopic
Bowel [mass-like]
Hemorrhagic corpus luteum cyst
Abdominal

Severely retroflexed uterus
Bicornuate uterus
Cervical


Impending or incomplete abortion
Degenerating cervical myoma
Chronic ectopic

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Pelvic inflammatory disease
Degenerating myoma
Endometrioma
Interstitial

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Myoma
Bicornuate uterus with pregnancy in horn

Abortion (AB)
Interruption of a pregnancy
Causes of AB
Induced
Spontaneous
Fetal malformation
Hormone inadequacies
Defective implantation
Placental maldevelopment or separation
Rh incompatibility
Systemic infection or toxic agents
Maternal trauma
Multiple fibroids/submucosal fibroids
Varieties of AB
Spontaneous AB
Inevitable AB
Incomplete AB
Complete AB
Missed AB
Septic AB
Spontaneous AB
Abortion before 20 weeks gestation
Mostly 5th-12th week
Vaginal bleeding
Possible no knowledge of pregnancy
May require D&C
Type
Threatened AB (clinical diagnosis)
Vaginal bleeding in early preg
Mild cramping
Possible visible fetus
Sac in Isthmus of uterus
Not dilatation of cervix
50% go on to abort
US findings of SAB
Check sac placement
It should be high for normal preg.
Check sac appearance
Is there a double decidual sign
Uterine size
Most likely there will be a recheck
for any changes
Sono Findings - Poor Outcome
Abnormal Hi/Low hCG
Large subchorionic hematoma
Heart rate <80 bpm
Abnormal sac size/ embryo size
Sac size too small or too big compared to
embryo
Distorted sac shape
Low position in endometrial cavity
Beware if heart beat seen, then this takes
precedence to show live IUP over all the above
D&C
Dilatation and
Curettage
Scraping of the
endometrium
Can leave scarring
Inevitable AB –
In Progress
Incomplete AB
Partial evacuation of fetus and placenta
Some retained products, Fetus expelled
Placenta usually remains
Signs & Symptoms
Usually pain
Bleeding/clotting
D & C needed
Sonographic findings
Still increase in uterine size
Thick heterogeneous and echogenic endometrium
w/hypervascularity
Complete AB
The entire pregnancy is totally
expelled
Sonographic findings
Increase in uterine size
No gestational sac or fetus seen
Decidual reaction might still be visible
Missed AB
Uterus small for date
(SGA)
No fetal heart motion
Retention of dead
pregnancy for at least 2
months
Fetus and placenta
retained before 18-20 wks
Placenta remains attached
Amniotic fluid reabsorbed
Sonographic findings
Fetus doesn’t occupy whole
uterus
Fetus may be macerated
Shapeless, ill defined
echoes
Poor imaging
No amniotic fluid to
delineate structures
Fetal demise
Fetal skull plates may
overlap – “spaulding sign”
Septic AB
Infected dead fetus
May show gas formation
Gas in uterus from bacteria
How does gas show up on US?
Abortions
Threatened AB due to early abruption
of placenta, can correct itself
spontaneous
Blighted Ovum
Anembryonic pregnancy
Sac with no fetal pole
Positive beta hCG
Different growth rates of GS
Small GS and large uterus
Increasing GS size and normal uterus
Blighted Ovum
Intrauterine sac with no
fetal pole
Irregular borders or ill
defined
Like a spontaneous or
incomplete AB
Vaginal bleeding
Check sac size with LMP
Hemorrhage
Innocent bleed
Small period 1 month s/p conception
Implantation bleed
Abortions
Chorioamniotic elevations
Extrachorionic bleed
Usually not serious concern
Subchorionic
Blood accumulation between chorion & decidua vera
Subchorionic hematoma/hemorrhage
Subchorionic hematoma/hemorrhage
Pseudogestational Sac
Free fluid within the endometrium
Can simulate an IUP early on
Typically the sac size is irregular and
there is not a pronounced double
decidual sign
+/- slight echogenicity around the pseudo
sac
No yolk sac and or fetal pole are signs of a
pseudo sac
Other considerations for pelvic mass
Persistent corpus luteum
PID/TOA
Appendiceal abscess
Endometrioma
Dermoid
Hydrosalpinx
Hemorrhagic or ruptured ovarian cyst
Fluid filled bowel
In these cases what is an important ? To ask
Molar Pregnancy
gestational trophoblastic disease
Increase in HCG x 10 for current age of
pregnancy
Remains elevated after 60 days
Previous mole
Associated with
missed AB or blighted ovum
Theca lutein cysts
Occur w/ 20-50% of molar pregnancy
Form in response to increase HCG
Usually large and multiloculated
Bilateral
Resolve after mole removed
Molar Classification
Hydatidiform mole (complete)
Partial mole
Coexisting fetus and mole
Locally invasive mole
Metastatic choriocarcinoma
Hydatidiform Mole
Hydatidiform Mole
Partial Mole
Coexisting fetus and molar preg
By def.- dizygotic twin gestation
Mole complete or partial
Fetus
Can become invasive
Locally Invasive Mole
Aka- chorioadenoma destruens
Invasive but does not metastasize
By def.- chorionic villi penetrate
myometrium
Can have invasion of bladder wall with
hemorrhage of local vessels
Extensive proliferation
Villi pattern preserved
Metastatic Mole
Choriocarcinoma
Molar Pregnancy Symptoms
Vaginal bleeding may be present with pain
Increase hCG
LGA- rapid growth
Hyperemesis
This is the most common of all the symptoms
Signs of preeclampsia (HTN, proteinuria,
edema)
Theca lutein cysts
Vessicles passed vaginally (not typical)
Leiomyomas / fibroids
Common pelvic tumor (esp. >35 year old)
Fibromuscular, most are benign
Etiology
Ovarian hormone imbalance
Feed on estrogen and get larger
Characteristics
Variable size
Vascular and can degenerate
Can have central cystic necrosis
Calcify over time
Very dense
Leiomyomas / fibroids
Presentation during pregnancy
1Tri. Can cause SAB
3Tri. Can interfere with delivery or precipitate preterm labor
Symptoms
Asymptomatic
Increase sensation to urinate
Pain
Profuse/prolonged bleeding
Enlarged and irregular uterus
Sonographic findings
Depends on location, changes and internal characteristics
Hypoechoic and heterogeneous
Ring of blood flow
Attenuate sound
Can look like molar pregnancy
Leiomyomas / fibroids
Cystic Hygroma
Cystic lymphangioma
Anomalous development in communication
between venous system and lymphatic
Mostly benign
Looks similar to meningomyelocele but no
bony defect
Sonographic findings
Multi septated cystic mass
Evaluate spine for defect and herniating mass
Nuchal Translucency
11-13 weeks gestation
Don’t get this mixed up with nuchal fold
done later in pregnancy
Watch out for amnion
Should be less than 3mm
Bounce
Fetal Demise
Review …
A patient presents for ultrasound at 7 weeks gestation
with bleeding and acute pain. The patient also reveals
a history of endometriosis. The sonographer
identifies a uterus without evidence of an IUP. This
would suggest?
Ectopic pregnancy
Threatened abortion
Missed abortion
Incomplete abortion
Spontaneous abortion
Review …
What is the most common patient
presentation of an ectopic pregnancy?
What are the risk factors for an ectopic
pregnancy?
What are diagnostic criteria
[sonographic & lab] for an ectopic
pregnancy?