Early Pregnancy Step by Step PDF

Early Pregnancy Step by Step Zacharias Fasoulakis Obstetrics & Gynecology Department of Prenatal Screening 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens Goals 4-10 week assessment by US 1. Normal appearance gestational sac (GS), yolk sac (YS) and emb...

Early Pregnancy Step by Step Zacharias Fasoulakis Obstetrics & Gynecology Department of Prenatal Screening 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens Goals 4-10 week assessment by US 1. Normal appearance gestational sac (GS), yolk sac (YS) and embryo 2. Assessment of mean sac diameter (MSD) and CRL 3. Viability criteria and terminology in non-viable pregnancy 4. Recognition of ectopics, principles of pregnancy of unknown location (PUL) 5. Role hCG and management of PUL 6. Molar pregnancy Conception and implantation  Embryo from 0-8 weeks......... Source: The Virtual Human Embryo Project  Implantation > gestational sac , , , , Chorionic / cavity " \. f I · : f t f t I I f t f '........ ":::J 1st evidence pregnancy on ultrasound; completely embedded blastocyst 14 days post conception NEJM 2001 ;345/1400  Gestational sac 1. Small, round fluid collection inside uterine cavity 2. Normally positioned in mid-to upper uterine cavity 3. Surrounded by a hyperechogenic rim 4. Visible at approximately 5 weeks of gestation 5. Beware of difference in gestational age and embryo age LOCATION OF GESTATIONAL SAC WITHIN UPPER HALF OF UTERUS 4° weeks - 2 mm 1st choice: Repeat Scan 2nd Choice: serum b-HCG 48h measurements  Gestational sac measurement - Mean of 3 orthogonal planes Growth in early pregnancy 1mm/day Knez et al Best practice Reseach Clin 0 & G 2014;28:621-36  Yolk sac 1. First structure identified within gestational sac 2. Confirms intra uterine pregnancy, 100% PPV 3. Spherical in shape 4. Echogenic periphery 5. Sonolucent center 6. Attaches to embryo by vitelline duct  Yolk sac 1. Imaged 5 - 5.5 w 2. Imaged when MSD > 5 - 6 mm 3. Imaged 3 - 5 d prior to embryo 4. Diameter peaks at 6 mm at 10 w then decreases 5. Usually not visible after first trimester Yolk sac 5 + 74 weeks Yolk sac in multiple pregnancy Dichorionic diamniotic Monochorionic diamniotic Monochorionic monoamniotic  AMNION 1. First seen - 5.5 w - small membraneous structure continuous with the embryo 2. Contains clear fluid 3. Separates the embryo and amniotic space from the extraembryonic coelom 4. Obliterates the coelomic cavity by 12-16 weeks  Heartbeat use M-mode 2 0 0.... - - - - - - - - - 111 180 160 140 120 100 5 6 7 8 9 10 11 12 13 14 15 16 Heartbeat visible > CRL > 2-4 mm Rapid frequency 5-9 weeks Use M-mode  Crown Rump Length (CRL) 1. ISUOG guideline 2. Midline sagittal section of whole fetus 3. Ideal orientation horizontally 4. Magnification fill most of width of screen 5. Fetus in neutral position 6. Amniotic fluid between chin and chest 7. Endpoints clearly defined ISUOG guideline 1st trim us scan UOG 2013;41:102-113 Embryo 6-8 weeks 94 weeks 10 weeks c  Practical rules early pregnancy Gestational age Measurement Gestational age Measurement (weeks) (weeks) GS 4 2 mm 5 10 mm YS 5 2 mm 5 3 mm Heartbeat 54 70 bpm 64 110 bpm CRL 53 3 mm 64 6 mm Movement 7 7 CRL (in cm) + 6,5 =GA in weeks  PAIN & BLOOD LOSS IN EARLY PREGNANCY Event Frequency Pain & vaginal bleeding 1:5 pregnant women Blood loss 50% continue into normal pregnancy 50% remaining blood loss Non viable, of which 10-15% ectopic pregnancy Pain in early pregnancy Obstetric cause: Miscarriage, ectopic, haemorrhage ruptured corpus luteum cyst, ovarian torsion Non-obstetric cause: Cystitis, appendicitis, ureteric stones, constipation Knez et al Best Practice Res Clin 0 & G 2014·28·621-636 Guideline TV US intrauterine pregnancy failure and uncertain viability  Uncertain viability 62 weeks GS and YS, no heartbeat Repeat scan 1 week GESTATIONAL SAC: FAILING PREGNANCY 100 95% o - 6 7 8 9 10 11 12 13 14 weken  Twin pregnancy with vanishing twin Evron et al Fertil Steril 2015;103:1209-14 HAEMATOMA  MISCARRIAGE 8 weeks no heartbeat Sites of ectopic pregnancy Early pregnancy: normal values of hCG ECTOPIC PREGNANCY  Interstitial pregnancy Interstitial pregnancy Cervical ectopic pregnancy Gestational sac in lower segment in cervical canal Gestational sac in lower segment - in cs scar  HETEROTOPIC PREGNANCY Prevalence heterotopic pregnancy Spontaneous pregnancy 1:30,000 ART pregnancy 1:100-500 Intrauterine Ectopic Maruotti & Russo Fert Ster 2010;94:e49  Hydatiforme mole HCG 330.000IU/L Complete Partial Prevalence 1:1500-2000 Prevalence 1:700 46, XX only paternal 69 XXX of 69 XXY (triploidy), paternal and maternal Persisting throphoblast 15% Persisting throphoblast 2% Hydatiforme mole  Hydatiforme mole in twin pregnancY Blood loss and abdominal pain 8 weeks US dichorionic twin pregnancy of which 1 mola hCG 439.467 IU/I Prevalence 1:10.000-100.000  Conclusion 1. Aware of normal appearance and assessment GS, YS & embryo from 4 weeks gestational age onwards 2. Criteria and terminology of viable and nonviable pregnancy 3. In doubt about viable intrauterine pregnancy: repeat scan 1 w 4. Scan uterus and ovaries to recognize ectopics 5. Management of PUL and role hCG and progesteron 6. Molar pregnancy appearance and pitfalls 7. In doubt of location of pregnancy: repeat scan within 2 days