Early Pregnancy

Dr S Chawla Dorma, Ghana November 2013

Role of US in Early pregnancy

Confirm: Presence of live intra-uterine pregnancy Gestational age Number of fetuses
Exclude: Early pregnancy failure Ectopic pregnancy Molar pregnancy Other pathology

Technique
Transabdominal scan 3.5 5 MHz Full bladder Entire pelvis visible Transvaginal scan 7.5 MHz Empty bladder 8 10 cm depth only

Technique
Begin in LS plane Use wide FOV Identify bladder Look for gestation sac Look for yolk sac or embryo Check for heart pulsatations Transverse Scan out towards both adnexa

Anatomy
Gestation sac

Bladder

Sac containing yolk sac and Body of Fetal pole Uterus Cervix

Estimating gestational age

1. Gestational sac size

Add 3 measurements, divide by 3, add 30, divide by 7

Estimating gestational age

2. Crown rump length (CRL)

Zoom the image Find the longest axis of the embryo Measure from crown to rump
If CRL > 85mm, measure HC instead

Early pregnancy abnormalities

Embryonic demise Multifetal pregnancy Retained products of conception Molar pregnancy Ectopic pregnancy Subchorionic haemorrhage Some fetal abnormalities

Embryonic demise (EPF)

1. Empty sac sign
MSD > 20mm with no visible yolk sac

20mm

CAUSES: Missed miscarriage Anembryonic pregnancy Pseudo sac from ectopic pregnancy

Embryonic demise (EPF)

2. Absent fetal heart pulsatation
Embryo CRL > 10mm with no FH = EPF (Transabdominal) If unsure: Use M mode Use Doppler Get a second opinion

Ectopic pregnancy (1)

Implantation of pregnancy outside endometrium 0.3-1.6% of pregnancies, 10% of maternal deaths Role of ultrasound is to locate pregnancy Intra-uterine pregnancy = ectopic excluded

IMPORTANT FACTS: Normal ultrasound does not exclude ectopic Must be correlated with clinical findings -hCG > 1000 iu = embryo should be visible If the patient is collapsed, do not delay treatment

Ectopic pregnancy (2)

Possible ultrasound features of ectopic

Intra-uterine pseudo sac

Solid adnexal mass with doughnut appearance

Ectopic pregnancy (3)

Possible ultrasound features of ectopic

Thickened echobright endometrium

Ectopic pregnancy (4)

Possible ultrasound features of ectopic

Bladder Solid adnexal mass

Ectopic pregnancy (5)

Possible ultrasound features of ectopic

Molar pregnancy
Present with bleeding and hyperemesis Caused by excessive proliferation of placental tissue Occasionally fetal tissue forms (non-viable) Elevated hCG levels 10% develop into malignant choriocarcinoma

Molar pregnancy
Appearance of molar pregnancy

Enlarged echobright endometrium

Multiple cystic spaces

Retained products of conception

Echobright or heterogenous material within endometrial cavity

Multifetal pregnancy
Assess viability of all fetuses Identify presence or absence of dividing septum Look for lambda sign THICK DIVIDING MEMBRANE = DCDA THIN DIVIDING MEMBRANE= MCDA

Associated findings
Intra-uterine fibroids

Associated findings
Ovarian cysts

Early fetal abnormalities

Anencephaly

Early fetal abnormalities

Megacystic baldder

Early fetal abnormalities

Gastroschisis/omphalocele

Troubleshooting
To improve image quality: 1. Ensure patient has full bladder 2. Use multiple focal zones 3. Narrow FOV and use zoom 4. Use M mode, Doppler and Transvaginal scanning if available

Troubleshooting
To help visualise ovaries: Use the bladder as a window
Scan left ovary from the right Scan right ovary from the left

Face

Nasal Bone

Heart

Kidneys

Spine

Limb

Calvarium, choroids and midline

Placenta

Troubleshooting
REMEMBER: Always consider the clinical picture and not just the ultrasound picture!