September 28 30, 2018€¦ · Ultrasound of Early Pregnancy Often the only finding is . . ....

Course Director

September 28-30, 2018

Early Pregnancies of Unknown Location or

Unknown Viability

Carol B. Benson, MD No Disclosures

Early First Trimester Ultrasound

Is the pregnancy intrauterine?OR

Is the pregnancy ectopic?

Is the pregnancy viable*?OR

Is the pregnancy a miscarriage

*Has potential to result in live born infant

Terminology & Definitions

Intrauterine Pregnancy of UnknownViability (IPUV)

Ultrasound findings: Intrauterine gestational sac with no

embryonic heartbeat

Pregnancy of Unknown Location (PUL)hCG & Ultrasound findings:

No intrauterine gestational sac oradnexal mass

Early pregnancy failureNot: Miscarriage, spontaneous abortion…

Terminology & Definition

Intrauterine Pregnancy of Uncertain

Viability (IPUV)

Ultrasound findings:

Intrauterine gestational sac with

no embryonic heartbeat

Terminology & Definition

Pregnancy of Unknown Location

(PUL)

hCG & Ultrasound findings:

No intrauterine gestational sac or

adnexal mass

Usually seen on transvaginal

ultrasound by 5.0 weeks

Intrauterine Sac-Like Structure1st Sign of Pregnancy

Beyene Double sac TV

Early Pregnancy – Transvaginal Scan

Published Ultrasound Signs ofEarly Pregnancy

Double sac sign* (reported 1982)

Intradecidual sign* (reported 1984)

*If present, diagnosis = IUP*If absent, does not mean no IUP

IUP = intrauterine pregnancy

Ultrasound Signs ofEarly Pregnancy

Double SacSign

IntradecidualSign

Areizaga Double sac TV

Intradecidual sign

Zanakos Double sac TV

Intradecidual sign

Perez doublesac sign

Double sac sign

Ultrasound of Early Pregnancy

Often the only finding is . . .

Nonspecific fluid collection in

central echogenic portion

of uterus (decidua)

Brown 5w

Early Pregnancy

5.0 weeks 18.0 weeks

Early IUPs from PD10,11,13,14

Early Pregnancies

Problem

If nonspecific fluid collection incentral echogenic portion of uterus

reported as no intrauterine pregnancyor the possibility of

a “pseudogestational sac”↓

Clinician concludes ectopic pregnancy↓

Patient treated with Methotrexateor dilatation & curettage (D&C)

Problem

When early intrauterine pregnancyis exposed to Methotrexate (MTX)

↓Follow up: intrauterine pregnancy

with heartbeat

↓Miscarriage or fetal malformations

Two readers assessed

199 proven intrauterine gestations

fluid in uterus, no YS or embryo

embryonic heartbeat on follow up

First trimester outcome

148 (74.4%) live

51 (25.6%) miscarriage

Study of Ultrasound Signs ofEarly Pregnancy

Signs of early

pregnancy

Double Sac Sign Intradecidual Sign

No Sign“Nonspecific”

Signs (or Absence of Signs) of Early Pregnancy

Reader 1 Reader 2DSS present* 32% 30%IDS present** 23% 39%Neither sign 57% 48%

Kappa = *0.24 & **0.23 (poor inter-observer agreement)

No relationship between outcome and presence/absence of DSS & IDS(p > 0.10, Fisher exact test)

Study of Ultrasound Signs ofEarly Pregnancy

Early Intrauterine Gestation

Early intrauterine gestations oftenhave a nonspecific appearance(>50% in our study)

Even in the absence of an intradecidual sign or a double sac sign,it’s most likelyan early intrauterine gestation


How should one report anIntrauterine fluid collection with

no yolk sac or embryo andnormal adnexa?

“Intrauterine sac-like structure that isalmost certainly an intrauterinegestational sac”

OR“Probable early intrauterine gestation.

Follow up ultrasound suggestedfor definitive confirmation”

“Pseudogestational Sac”

Definition:

Fluid in the uterine cavity

mimicking a gestational sac

with ectopic pregnancy

Misuse of Term Pseudogestational Sac

Definition: fluid in uterine cavity

with ectopic pregnancy

Frequency with ectopic pregnancy

1979 report: 20%

1990 reports: 10%

Intrauterine Fluid in Ectopic Pregnancy: A Reappraisal

All proven ectopic pregnancies July 2008 to August 2011 = 229 cases

Fluid, when present, characterized by Shape:

pointy-edged or smooth*Location:

clearly in cavity* or uncertainFluid contents:

echoes & debris or anechoic*

*Features of early intrauterine pregnancy

Intrauterine Fluid in Patients With Ectopic Pregnancy

No fluid83.4%

Fluid16.6%

Intrauterine Fluid in Ectopic Pregnancy: Fluid Characterization

Fluid inconsistent with gestational sacpointy-edgedclearly within uterine cavity

(not the decidua)containing echoes or debris

Fluid similar to a gestational sacsmooth marginsnot clearly within uterine cavityanechoic

Intrauterine Fluid in Ectopic Pregnancy: Inconsistent with Gestational sac

Pointy-edged Internal echoes Within cavity or debris not decidua

30/38 28/38 7/38

38 ectopics (16.6%) had fluid in cavity

Intrauterine Fluid in Ectopic Pregnancy: Similar to Gestational sac

Smooth, anechoic, not clearly within cavity7/38

38 ectopics (16.6%) had fluid in cavity

No fluid83.4%

Fluid: Inconsistent with gestational sac

13.5%

Fluid: Similar to gestational sac

3.1%


Jimenezdecid cyst & EP

7 with fluid similar to a gestational sac5 had adnexal mass of ectopic

(2 no mass)

RO


Fluid: Similar to gestational sac(“Nonspecific”)

&No adnexal mass

(extraovarian)0.9%

Calculations

Intrauterine gestations 98%Nonspecific fluid 50%

Ectopic pregnancies (per CDC) 2%Nonspecific fluid & no mass 1%

For nonspecific fluid collection in cavity& no adnexal mass

Do the math…99.9% likelihood of intrauterine

pregnancy (>1000 to 1)

hCG & Nonspecific Intrauterine Fluid CollectionGestational Sac or Pseudogestational Sac?

11 dayslater

7 dayslater

16 dayslater

With transvaginal scanning

diagnosis of ectopic pregnancy

is made earlier than in the past

In absence of adnexal mass,

fluid in uterus much more likely

an intrauterine gestation (99.9%)

than a “pseudogestational sac”

“Pseudogestational Sac” “Pseudogestational Sac”

Definition:Ectopic pregnancy with

fluid in the uterusmimicking a gestational sac

Avoid this term!The fluid is almost always an

intrauterine pregnancy

Don’t mistake

an early intrauterine gestation

for an interstitial ectopic pregnancy.

The gestational sac can be

eccentrically located in the

uterine cavity.


Keshishian eccentric IUP

5.5 week intrauterine gestation

Keshishian eccentric IUP

5.5 week intrauterine gestation

Chafe eccentric IUP

6.0 week gestation

Transabdominal Transvaginal

Chafe eccentric IUP

2 days later3D reconstruction

Yolk Sac

Usually seen on transvaginal

ultrasound by 5.5 weeks

Usually seen when

mean sac diameter > 10 mm

Visualization of yolk sac confirms

gestational sac is a pregnancy

Thompson YS TV

Fetal Cardiac Activity

Usually seen on transvaginalultrasound by 6.0 weeks

Visualization of embryonic heartbeatconfirms viability

Kelly early FH

Embryonic heartbeatGA = 6.0 weeks

Inostroza fetal pole& FH

6 weeksgestation

4.2 mm

121 bpm

Pregnancy Failure

Most frequent early in pregnancy:

6 - 8 weeks with heartbeat10 - 17% will be lost

After 8 weeks with heartbeat< 4% will be lost

Increased loss ratesExisting conditions

Prior miscarriages

Uterine duplication anomalies

Fibroids

Advanced maternal age

Pregnancy Failure

Increased loss ratesOnce pregnant

Bleeding

Slow fetal heart rate

Subchorionic hematoma

Pregnancy Failure

Definitive diagnosis

Embryo ≥ 7 mm* with no heartbeatMean sac diameter ≥ 25 mm*

with no heartbeatNo heartbeat & gestational age

2 wks after gestational sac seen*(GA >7 wks by prior ultrasound)

Sliding sac

Pregnancy Failure

*SRU Consensus Panel on Dx of Early Pregnancy Failure 2012

Pregnancy Failure

Findings on follow up ultrasound

*SRU Consensus Panel on Dx of Early Pregnancy Failure 2012GS = gestational sac; YS = yolk sac

Rationale for ≥ 7 mm cutoffSet value to virtually eliminate

any false positive diagnoses(100% specificity)

Prior criteria not stringent enoughBased on small numbers of cases

Need to account for interobservervariability (± 15%)

Pregnancy Failure by Crown-Rump Length (CRL)

Catlin CRL 2mmNo FH; +FH at F/U

6 weeks2.5 mm

Catlin CRL 2mmNo FH; +FH at F/U

One week later (7 weeks)

Schultz 7.5 mmNo FH

7.5 mm embryo

Rationale for ≥ 25 mm cutoffSet value to virtually eliminate

any false positive diagnoses(100% specificity)

Prior criteria not stringent enoughBased on small numbers of cases

Need to account for interobservervariability (± 19%)

Pregnancy Failure by Mean Sac Diameter (MSD)

Schwartzbergfailed preg large MSD

Failed pregnancy

Mean sac diameter (MSD)(35 + 20 + 28) 3 = 28 mm

Sliding Intrauterine Gestational Sac

Gestational sac within uterinecavity, not embedded in decidua

Shifts position within uterinecavity on realtime scanning

Zhang SAB sliding sac

Failed pregnancy – Sliding sac

Pregnancy Failure



Olson MSD 14 mm

Empty Gestational Sac 16 days (2.3 weeks) After Small Gestational Sac Seen

MSD = 14.1 mm

Suspicious but not definitive

Embryo < 7 mm with no heartbeat

larger the embryo, higher the risk

Mean sac diameter 16 - 24 mm

with no heartbeat

> 6 weeks gestation by LMP with

gestational sac, but no embryo

Pregnancy Failure

Gradineau 6mmNo FH

6.2 mm embryo

Costi TVlarge GS

Suspicious for Failed pregnancyEnlarged empty gestational sac (MSD = 19.3 mm)

Pregnancy Failure



High likelihood of subsequentpregnancy failure

Small sac size (MSD – CRL < 5 mm)even with heartbeat

Embryonic bradycardia(the slower the rate,

the greater the risk)Large subchorionic hematoma

size > 50% gestational sac size

Pregnancy Failure

Sullivan small GS then demise

Suspicious for Failing PregnancySmall sac size

MSD = 10.1CRL = 11.2

∆ = ─ 1.1 mm

Sullivan small GS then demise

Suspicious for Failing PregnancySmall sac size

Demise 10 days later

Associated with first

trimester pregnancy loss

Especially for FHR < 90 bpm

Slow Embryonic Heart RateConn slow FH

6 weeks

Gestational age 6.2 weeks

FHR Miscarriage

<80 ~100%

80-89 69%

90-99 32%

100 11%

Slow Embryonic Heart Rate Slow FH

6 weeks

Gestational age 6.3 - 7.0 weeks

FHR Miscarriage

<100 93%

100-109 44%

110-119 14%

120 6%

Slow Embryonic Heart RateKiernan slow FH

6.6 weeks

102 bpm

6 mm

Kiernan slow FH f/u

One week follow up 5 mm

Ongoing Pregnancy with Bleeding

With living embryo

Risk of subsequent loss

Subchorionic hematoma

loss with hematoma size

Subchorionic Hematoma& Live Embryo

Prognosis (risk of failed pregnancy)*Hematoma sizeGestational age at diagnosisMaternal age

Gestational Age (Weeks)6.0-7.0 7.1-8.0 8.1-11.0

Demise % 19.6% 14.6% 3.6%Maternal Age (Years)<35 ≥35

Demise % 9.6% 19.6%*n=434; demise by end of 1st trimester

Which method is best for assessinghematoma size? Subjective: small, moderate, large? Size compared to gestational sac?

(%): ≤10; 10-25; 25-50; >50 Fraction of gestational sac

surrounded by hematoma? (%): ≤10; 10-25; 25-50; >50

3 orthogonal measurements tocalculate “volume”?


Diaz 5.5 w SCH mod

Subchorionic hematoma – 5.5 weeks

Subjective size: Moderate Hematoma size >50% size of gestational sac Surrounds 25-50% of gestational sac Measured 19 x 16 x 10 mm

Size compared to gestational sac(%): ≤10; 10-25; 25-50; >50

Correlated best with outcome (p<0.001)X Subjective: small, moderate, large

(p=0.142)X Fraction of gestational sac surrounded

(%): ≤10; 10-25; 25-50; >50 (p=0.085)X 3 orthogonal measurements

calculate “volume” (poor correlation, spurious results)


434 pregnancies 6-11 weeks

434 pregnancies 6-11 weeks*

Hematoma Size as Fraction of Gestational Sac Size (p<0.001)≤10% 10-25% 25-50% >50%

Live* 114 112 66 89Demise 7 11 8 27

Demise % 5.8% 8.9% 10.8% 23.3%

*Live at end of 1st trimester


Subchorionic Hematoma

266 pregnancies 6-8 weeks*

Hematoma Size as Fraction of Gestational Sac Size (p<0.05)

≤10% 10-25% 25-50% >50%Live* 54 53 45 68

Demise 5 11 7 23Demise % 8.5% 17.2% 13.5% 25.3%

*Live at end of 1st trimester

Cox 7 w SCH

Subchorionic hematoma – At 7 weeks

Cox 9w SCH f/u

Subchorionic hematoma – At 7 weeksFollow up, Demise – At 9 weeks

Hussar SCH large

Subchorionichematoma

6 weeks 12 weeksResolved

Recommended follow up of suspicious but not definitive findings (IPUV*)

Ultrasound, not hCG

7-10 days (in most cases)

Pregnancy Failure

*Intrauterine pregnancy of unknown viability

hCG & Pregnancy Failure*


UltrasoundFinding

Key Points

Nointrauterine

fluid collection

Normal adnexa

• If a single hCG is >3000 mIU/ml and the uterus is “empty” on U/S, a normal IUP is very unlikely

• A single hCG should not be used as a criterion for definitive exclusion of a potentially normal intrauterine pregnancy

• A single hCG, regardless of its level, does not reliably distinguish between ectopic and intrauterine pregnancy, and does not justify presumptive treatment for ectopic pregnancy using methotrexate or other medical/surgical means.

Diagnose Multiple Gestations

Twins 1 / 80 - 90 deliveries

Triplets 1 / 8000 deliveries

Quads 1 / 729,000 deliveries

Quints 1 / 65,610,000 deliveries

Nelson quads clip Undercounting Multiple Gestations

Before 6 weeksUndercount

rate

Dichorionic twins 11%

Monochorionic twins 86%

Higher order multiples 16%

Overall 14%

Atlas 23.1-6 appearingtwin Monochorionic

5.0 weeks – 1 Gestational sac

5.5 weeks – 2 Yolk sacs

10.0 weeks Monochorionic twins Prognosis:

Undercounted vs. correctly counted

No difference (p > 0.20) in

Fetal loss rate

Gestational age at birth

Birthweight

Undercounting Multiple Gestations

Atlas 23.1-7appearing triplet

5.0 weeks 6.5 weeks

St Jean appearing quad

5.5 weeks 7.0 weeks

Lewis CRL 7w

7 weeks

Thank youRichardson clip

September 28 30, 2018€¦ · Ultrasound of Early Pregnancy Often the only finding is . . ....

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