Sonography of First Trimester Pregnancy

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Pelvic Ultrasound indications

 Amenorrhoea
 Pelvic pain
 Vaginal bleeding
 Unknown last normal menstrual dates
 Subjective feeling of pregnancy
 Uterus greater or smaller than dates on clinical evaluation
 Pregnancy test positive or increased hCG values
 Infertility
 Nuchal translucency measurement

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 Pelvic Anatomy

Uterus
F. tubes
Ovaries
Bladder

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 Uterus Anatomy
 Pear shaped organ
 Lies anterior to sigmoid colon and
posterior to bladder
 Average size: 8 x 5 x 3 cm
 Comprised of 3 layers:
 Serosa Uterus
 Myometrium
 Endometrium: is an important
ultrasonographic structure Pubic Bladder
Bone Sigmoid Colon
 Orientation
 Anteverted , Anteflexed
 Retroverted , Retroflexed

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Flexion
 Relationship of the uterine body to the cervix
Version
 Relationship of the uterine body to the vagina

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 Myometrium
mid level echogenic and transitional zone is
hypo echoic next to endometrium
Endometrium
- highly echogenic strip in longitudinal and
central echogenic in transverse scans
- thickness depends on the phase TA U/S sagittal v. Three layered
proliferative phase endometrium ( b/n
- throughout the uterus and cervix
arrows)
- Seen as a double layer

Ali. B (MRT) TV U/S sagittal view ---uniformly

11
echogenic secretary phase
endometrium( b/n arrows)
 Fallopian Tubes

 Located below fundus

 Average size: 1- 4 mm in diameter and 10-12cm long
 Four segments
 Isthmus
 Ampulla
 Infundibulum
 Fimbriae
 Only visible on US when dilated

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 Ovaries
 Located anterior and medial to internal iliac vessels

 Average size: 4 x 3 x 2 cm

 Follicles determined by menstrual cycle

 Early: 5-11 follicular cysts

 Near Ovulation: dominant follicle 15-20 mm

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  Posterior and lateral to the uterus
 Usually oval in shape and the size of a walnut
 Medulla and stroma

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 The Urinary Bladder
 Most anterior structure in pelvis

 Shape is dependant on plane of view as well as volume of urine contained

 Useful in transabdominal ultrasound as an acoustic window to visualize

the uterus.
A full bladder
 displaces bowel from between probe and anatomy in question
 enhances structures in distal field (acoustic enhancement)

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 Physiological changes in normal pregnancy

 Egg + sperm
 Zygote
 Morula – 12 or more cells enters
uterine cavity
 Blastocyct – two layers
 Trophoblast
 Inner layer

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First Trimester Pregnancy

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First Trimester pregnancy sonographic Indications
 Confirmation of pregnancy viability
 Established accurate gestational age
 Determine the number of fetuses
 Assess chorionicity and amniocity of fetuses
 To rule out pelvic masses

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First Trimester Pregnancy

 Structures of first trimester pregnancy

 Gestational sac
 Yolk sac
 Fetal pole or embryo
 Fetal cardiac activity

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  The early GS can be seen by TVS at 3.5 to 4.5 wks as a tiny cystic structure
implanted within the echogenic decidua: the intradecidual sign.

 A normal GS is visualized by TAS by 5wks.

 The normal GS appears on US as

 a smoothly contoured, round or oval, fluid-containing structure positioned
in the endometrial cavity near the fundus of the uterus.

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 Ultrasound assessment of gestational age(GA) is feasible in a majority of
pregnancies with greater accuracy than physical exam in the first trimester,
 GS mean diameter &
 CRL
measurements have become the primary means of evaluating GA.

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Intrauterine Pregnancy (IUP)
 Intradecidual Sign
 Earliest sign of Pregnancy
 Anechoic sac without a distinct chorionic ring
 Located lateral to endometrial strip
 Seen as early as 4wks

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 Gestational Sac
 Double decidual (sac) sign
 Endometrial cavity separates parallel crescents of echogenic decidua

decidua parietalis (vera)

decidua capsularis

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  Double Decidual
Sign
 embryo forms decidua
capsularis and
decidua Vera(decidua
parietalis)
 appears as separate
echogenic layers

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 Yolk Sac
 is a 2 to 6mm-diameter, spherical, cystic structure that is connected to the midgut of
the embryo by a thin stalk, the vitelline duct.

 The yolk sac is the earliest site of blood cell formation in the embryo.

 It is the earliest structure visualized within the GS and serves as an evidence of early
pregnancy.

 It should always be visualized in normal pregnancy in GS of 20-mm mean sac diameter

by TAS or 8-mm mean sac diameter by TVS.

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 Yolk Sac. The yolk sac (arrow) is seen within the GS by TVS. The normal
yolk sac is less than 6 mm in diameter, spherical, and fluid filled with a
thin wall. The yolk sac is in the fluid space between the thin membrane
of the amnion (white arrowhead) and the chorion (black arrowhead),
which defines the limit of fluid within the GS .
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Intrauterine Pregnancy

 Yolk Sac
 First structure seen within
the gestational sac
 Visible on U/S at 5-6 week GA

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 Signs of Abnormality

 Strong signs: TAS

 MSD > 20 mm without yolk sac

 MSD > 25 mm without embryo

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 Signs of Abnormality

Strong signs: EVS

MSD › 8 mm without yolk sac
MSD › 16 mm without embryo
The “empty amnion”:
amnion apparent but no embryonic pole

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Intrauterine Pregnancy
 Fetal Pole visible at 6
weeks
 sign of intrauterine
Pregnancy

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 US Characteristics of Normal GS
Intradecidual sign before 5 wks GA

Double decidual sac sign after 5 wks GA (>98% of IUP)

Well-defined round/or oval anechoic sac

Echogenic decidua >2 mm thick

Position in upper uterine body mid way between uterine walls

Growth in MSD >1.2 mm/day

Yolk sac 2 to 6 mm in diameter:

   Always present when MSD 20 mm on TAS
   Always present when MSD 8 mm on TVS
Embryo:
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   Always present when MSD 25 mm on TAS 36
   Always present when MSD 16 mm on TVS
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 US Characteristics of an Abnormal GS
Major criteria
Absence of yolk sac when:
   MSD 20 mm on TAS
   MSD 8 mm on TVS
Absence of embryo when:
   MSD 25 mm on TAS
   MSD 16 mm on TVS
Distorted sac shape
Growth <1 mm MSD/day
Minor criteria
   . Irregular sac contour
   .Thin decidual reaction <2 mm
   .Weak decidual echo amplitude
  . Absent double decidual sac sign
   .Sac positioned low in the uterus

GSD is measured in three orthogonal planes, and the measurements are averaged
to calculate the mean sac diameter (MSD).

US differentiation of the GS of early IUP from the pseudogestational sac of EP.

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[1MAJOR or 3MINOR] 38
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 Pregnancy Dating
 Dating the pregnancy and determining the appropriateness of fetal growth
are essential to obstetric care.

 Clinical dating: based on history of the mother's last menstrual period (LMP)
and bimanual assessment of uterine size.

 Sonographic dating: based on measurements of the gestational sac and the

embryo or fetus.
 Serial measurements of fetal parameters are used to document growth.

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 Pregnancy Dating cont’d…

 GA estimates are most accurate in early pregnancy and become

progressively less accurate as the pregnancy advances.

 The composite age, calculated by averaging GA estimates of multiple

parameters, is more accurate than any single parameter because fetal
anomalies may make individual parameters inaccurate for estimation of
GA.

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 Guidelines for the 1st TM U/S
 locate the gestational sac, identify the embryo and record the CRL.

 presence or absence of fetal life should be reported.

 fetal numbers should be documented.

 evaluation of the uterus and adenexal structure should be performed.

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 Gestational sac size

 The gestational sac is an echo-free space containing the fluid, embryo,

and extra embryonic structures.

 is used in the first trimester to estimate GA when no embryo is visualized.

 The gestational sac diameter is measured in three orthogonal planes,

and the results are averaged.

 The MSD is accurate to within approx 1 wk.

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 Look how to measure GS
 Gestational Sac
 Useful after 4 Wks GA
 Sac grows 1 mm/day

 Normally round, centrally located,

smooth walled

 yolk sac should be present when

gestational sac > 10 mm

 MSD = L+W+H
3

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 Crown-Rump Length
 is measured from the top of the head to the bottom of the torso of the
visualized embryo or fetus.

 The CRL is useful until about 10 to 12 weeks GA, when other fetal
measurements become more accurate.

 Provides GA estimations accurate to approximately 0.5 week.

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 Pregnancy Dating

 Crown Rump Length

 Useful after 6WGA
 Fetus grows 1mm/day
 Measure longest point
 Do not include yolk sac in
measurement

Crown-Rump Length (CRL). The CRL is

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of the head to
the bottom of the torso (between
cursors).
 Growing placenta

embryo
Gestational
sac

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 B- HCG

 No longer used to determine if US needed

 B-HCG > 1000 without gestational sac = Ectopic pregnancy

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 Approach
 Patients clinical history
 Urine test
 Proper sonographic examination request
 Interpretation of the ultrasound findings
 Correlation with clinical history

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 Diagnosis of abnormal early
pregnancy

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 Diagnoses

 Blighted ovum
 Embryonic death
 Abortion
 Ectopic pregnancy
 GTD

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 Blighted Ovum

 Gestational development is arrested before embryo formed

 Large empty gestational sac
 DDX:
 Early IUP
 Pseudogestational sac (ectopic)

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 Anembryonic pregnancy or blightened ovum is a pregnancy in which the
embryo has died and is no longer visible or never developed.
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 Blighted Ovum

 Diagnosis
 Compare MSD to presence of a yolk sac or an embryo
 The “empty amnion”
 Discrepancy between sac size and HCG level
 Abnormal appearance of sac:
 Weak decidual reaction, irregular sac contour, or distortion of the sac
shape

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 Diagnoses

 Blighted ovum
 Embryonic death
 Abortion
 Ectopic pregnancy

 GTD

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 Embryonic Death
 Absence of cardiac activity when embryonic pole is visible by TAS

 If an embryo with a CRL of < 5 mm shows

 no cardiac activity, follow-up ultrasound is indicated

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 Guidelines to establish embryonic death by ultrasound
proposed by Royal college of Obstetricians and Gynecologists

 The absence of Cardiac activity in an embryo of CRL > 6 mm, or a

yolk sac or embryo in a gestation sac of mean diameter > 20 mm,
enables conclusive diagnosis of a missed miscarriage.
 In pregnancies in which the embryo and sac are smaller than 6 mm
or 20 mm, respectively,
 a repeat ultrasound examination 1 week later is necessary to
clarify the diagnosis

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 Diagnoses

 Blighted ovum
 Embryonic death
 Abortion
 Ectopic pregnancy
 GTD

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 Abortion
 The termination of a pregnancy after, accompanied by, resulting in, or
closely followed by the death of the embryo or fetus:
 The deliberate termination of a human pregnancy.

 the natural expulsion of a fetus from the womb before it is able to survive
independently.
 Occurs before 20 wks

 10–15% of all known pregnancies

 60% of spontaneous abortions – chromosomal

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 •Largely a clinical diagnosis
•Types
Threatened abortion– closed cervix
Inevitable abortion– cervical dilatation & fetal or placental tissue within the
cervical os.
Complete abortion– all products of conception have been expelled

Incomplete abortion – is the expulsion of some, but not all, of the products of
conception

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 Missed abortion- the embryo or fetus dies, but the products of
conception are retained in utero.

Septic abortion- occur in infection of the uterus and sometimes

surrounding structures occur.

spontaneous abortion- naturally occurring expulsion of a nonviable

fetus

Habitual abortion – three or more successive spontaneous abortions

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 Fig. A case of missed miscarriage at 8 weeks’
gestation. An irregularly shaped gestation sac is seen
containing a small amniotic cavity (A) with no fetal
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pole. 69
 Abortion
 Ultrasound findings:
 GS extending into the cervix

 Deformed sac and embryo

 Embryo without cardiac activity

 Intrauterine mass with cystic spaces:

 Hydropic degeneration of the placenta
 Hydropic villi create a cystic appearance

 Empty uterine cavity

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 Diagnoses

 Blighted ovum
 Embryonic death
 Abortion
 Ectopic pregnancy
 GTD

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 Ectopic Pregnancy

 An ectopic pregnancy is defined as implantation of fertilized ovum outside

uterine cavity.
 1.4% of all pregnancies
 Increased 6X since 1970 (?PID)
 Causes ~ 1/4 of all maternal deaths
 > 95% are tubal
 Abdominal, ovarian, cervical ectopics are rare
 Risk factors:
 Infertility, PID, prior ectopic, H/O tubal surgery

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 Ectopic pregnancy locations

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 Ectopic pregnancy results if the blastocyst implants anywhere outside of the
uterine cavity.

The vast majority of ectopic pregnancies occur in:Ampulla Ectopic

Pregnancy --- 75% - 90%
Isthmic Ectopic Pregnancy --- 5% - 15%

Heterotopic pregnancy (one embryo in the uterus and one ectopic embryo):
1/7000

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 Cont…

 Specific US findings
 Unruptured live ectopic in the adnexa
 Demonstration of an IUP
 (coexistent ectopic odds: 1 in 7,000-30,000)

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 Cornual
Ectopic

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 The Exception to the IUP Rule:
Heterotopic Pregnancy

Fig. A case of heterotopic pregnancy.

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The lower sac (1) is implanted into the cervix,
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whereas
the upper sac (2) is normally located within the uterine cavity.
 Cont…

 Strong but not specific US findings

 Adnexal (tubal) ring sign:
 Echogenic trophoblastic tissue lining tube
 PPV is very high ~ 100%

 Large amount of fluid (blood) or complicated fluid (clot) in cul-de-

sac. PPV ~ 90%

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PPV- Positive predictive Value 83
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 Cont…

 Complex adnexal mass

 (often tubal hematomas)
 PPV ~ 85%

 Adnexal mass and free fluid, PPV ~ 95%

 Decidual cast. Pseudogestational sac

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 Predisposing factors
 Any factor that interferes with the normal fallopian tube
function**
 Previous tubal surgery.
 Previous ectopic pregnancy.
 In-utero diethylstilbestrol exposure.
 Previous gynecologic infections (PID).
 Treatment of infertility.
 Current cigarette smoking.
 Previous intrauterine device use.

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 You have to remember that!!!

Ectopic pregnancy should always be considered in women of

reproductive age presenting with abdominal pain.

The classic triad of ectopic pregnancy includes abdominal pain,

vaginal bleeding, and amenorrhea.

Transvaginal ultrasound is the modality of choice when diagnosing an

ectopic pregnancy.

 With hCG level> 1500mIU/ mL and no IUP identified on transvaginal

ultrasound, this is high risk for ectopic pregnancy.

Ectopic pregnancy is the leading cause of pregnancy related death in

the first trimester of pregnancy.

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 Diagnoses

 Blighted ovum
 Embryonic death
 Abortion
 Ectopic pregnancy
 GTD

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Gestational trophoblastic disease (GTD)
 is a term used for a group of pregnancy-related tumours.

 are rare, and they appear when cells in the womb start to
proliferate uncontrollably.

 The cells that form gestational trophoblastic tumours are called

trophoblasts and come from tissue that grows to form placenta
during pregnancy.

 In a normal pregnancy, trophoblastic cells aid implantation of

fertilised egg into uterine wall.
But in GTD, they develop into tumour cells.

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 GTD
 Neoplastic disease of trophoblast:
. Hydatidiform mole
. Invasive mole
. Choriocarcinoma

 US: Hyperechoic soft tissue mass filling uterus

 cystic degeneration of
mole; large multiseptated adnexal cysts

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 Causes

 Two main risk factors increase the likelihood for the development of
GTD:

1) The woman being under 20 years of age, or over 35 years of age, and

2) previous GTD

• Although molar pregnancies affect women of all ages,

6x higher risk -women <16 years of age
3x - women >=50 years of age
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 Hydatidiform mole

Hydatidiform moles are abnormal conceptions with

excessive placental development.

Conception takes place, but placental tissue grows very

fast, rather than supporting the growth of a fetus

Types

1- Complete mole

2- Partial mole

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 Two Types
Complete mole – classic mole 70%
• dispermic fertilisation of an empty ovum
. involves the entire placenta
. lacks a fetus
. diploid in karyotype

Partial mole (30%)

• dispermic fertilisation of a normal ovum
. involves only a portion of placenta
. an abnormal fetus
. triploid in karyotype

U/S features
. Complete mole – innumerable tiny cysts
“snow storm” appearance

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 Most common symptoms of GTD

Vaginal bleeding,
 enlarged uterus,
pelvic pain or discomfort, and
vomiting too much (hyperemesis)
Malignant forms of GTD are very rare.
About 50% of malignant forms of GTD
develop from a hydatidiform mole

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 TWIN PREGNANCY
 Incidence: 1% of live births

 TYPES:

 Dizygotic (Fraternal) – 70%

 Always – Dizygotic – Diamniotic

 Monozygotic(Identical) – mono/ dichorionic

 During the last 10 wks of pregnancy there is a decrease in the growth

rate for twin fetuses compared with singleton fetuses.

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 First trimester

 Features supporting a DCDA pregnancy:

 presence of two gestational sacs with a thick echogenic chorion

surrounding each embryo
 a thick inter twin membrane
 twin peak sign / Lambda sign
 two yolk sacs may be seen (this however does not differentiate a DCDA
pregnancy from a MCDA pregnancy).
 Sonographic assessment of chorionicity is most accurate in the first
trimester.

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 Second trimester

 when there is no placental fusion, two separate placental sites

may be seen

 a finding of two different genders for each twin is a definitive

feature for a dizygotic pregnancy which in turn will invariably
mean a DCDA pregnancy.

 If the twins are of the same gender then it is extremely difficult

if not impossible to determine if they are monozygotic or
dizygotic on ultrasound.

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Ali. B (MRT) 104
 Monochorionic twins

 Monozygotic (one egg/identical) twins as a result of when the

fertilized egg divides.

 Monochorionic twins are monozygotic (identical) twinsthat share

the same placenta

 Monochorionic twins occur in 0.3% of all pregnancies.

 75% of monozygotic twin pregnancies are monochorionic;

 the remaining 25% are Dichorionic Diamniotic. If the placenta

divides, this takes place after the third day after fertilization
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 A B

Fig. Twin pregnancy A- MCDA ( T-sign) & B- MCMA

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  COMPLICATIONS:

 DC, DA Twins – 10% Perinatal mortality

 MC, DA Twins – 20% Twin-Twin Transfusion,

Acardia, Twin embolization syndrome

 MC, MA Twins – 50%

 entangled cords
 conjoined –
 thorachopagus,
 omphalopagus,

 - Ectopic Twin pregnancy

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 Thanks for caring me & mom….

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