FIRST TRIMESTER ULTRASOUNDDr. Muhammad Bin ZulfiqarPGR IV FCPS Services Institute of Medical Sciences / Hospitalradiombz@gmail.com

AIMS• Assessment of gestational age

• Fetal viability and outcomes

• Maternal wellbeing

•

INDICATIONS• Unsure of Dates• Vaginal Bleeding• Pelvic Pain• Exclude an ectopic pregnancy• Threatened Miscarriage• Nuchal Translucency (11-13.6 weeks : CRL 45-84mm)• Maternal past history

HISTORY BEFORE US• Gravidity

• Parity (Miscarriage, Termination of Pregnancy (T.O.P))

• Fertility treatment

• Date of Last Menstrual Period

• Other pregnancy History

• Gynecological History

PROBE SELECTIONS• Curved linear probe approximately 3-7 MHz depending upon maternal factors• Transvaginal probe approximately 5-9 MHz (Use of non-latex cover if required

PATIENT PREPARATION• Emptying of bladder 2 hours before US, then drinking of at least 1 liter of water. Ask patient do not go to the toilet till exam

• For TVS approach empty bladder is needed

APPROACH • Confirm presence of intrauterine gestation• Look for double decidual reaction.• Look for no of gestational sacs. If multiple pregnancy

• Confirm number of fetuses • Number of sacs• number of placentas

• to determine chorionicity. • Monochorionic / Monoamniotic(MCMA)• Monochorionic / Diamniotic(MCDA)• Dichorionic / Diamniotic (DCDA)

Continued

APPROACH • Confirm heart beat & rate with M-Mode only (Use of Color or Doppler traces is not recommended in the 1st trimester)• Measure CRL to calculate gestational age and Estimated Date of Delivery(EDD).If too early to see the fetal pole measure the average sac diameter.

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APPROACH • Cervix - assess if closed and measure length between internal and external os• Assess placental location and distance from internal os (may lie close to os at this stage)• Check for retroplacental hemorrhages, placental masses etc.• Assess maternal ovaries, adnexa and Pouch Of Douglas (P.O.D)

TECHNIQUE• Uterus – longitudinal and transverse

• Both ovaries

• Adnexa

• Cervix and Pouch-Of-Douglas

• Gestational sac - longitudinal and transverse

Continued

TECHNIQUE• Yolk sac if visible

• Fetal pole

• M mode fetal heart

• Document the normal anatomy. Any pathology found in 2 planes, including measurements.

GESTATIONAL SAC• The gestational sac(GS) is the earliest sonographic finding in pregnancy. • It will be difficult to see if the mother has a retroverted uterus or fibroids. • The GS is an echogenic ring surrounding an anechoic centre. • An ectopic pregnancy will appear the same but it will not be within the endometrial cavity.

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GESTATIONAL SAC• The GS is not identifiable until approximately 4.5 weeks with a transvaginal scan.• Gestational sac size should be determined by measuring the mean of three diameters. These differences rarely effect gestational age dating by more than a day or two.

MEAN SAC DIAMETER TVS

• Mean Sac Diameter measurement is used to determine gestational age before a Crown Rump length can be clearly measured. The average sac diameter is determined by measuring the length, width and height then dividing by 3

YOLK SAC• The yolk sac appears during the 5th week. • It is the second structure to appear after the GS. • It should be round with an anechoic centre. • It should not be calcified, misshapen or >5mm from the inner to inner diameter. • Yolk sacs larger than 6 mm are usually indicative of an abnormal pregnancy. • Failure to identify (with transvaginal ultrasound) a yolk sac when the gestational sac has grown to 12 mm is also usually indicative of a failed pregnancy.

YOLK SAC TVS5 week gestation. Yolk Sac Only seen. The yolk sac should be visible before a clearly definable embryonic pole.

HEART BEAT• Using a transvaginal approach the fetal heart beat can be seen

flickering before the fetal pole is even identified. • It will be seen alongside the yolk sac. • It may be below 100 beats per minute but this will increase to

between 120- 180 beats per minute by 7 weeks. • In the early scans at 5-6 weeks just visualizing a heart beating is the

important thing. • Failure to identify fetal cardiac activity in a fetus whose overall length

is greater than 4 mm is an ominous sign.• Sometimes there is difficulty distinguishing between the maternal

pulse and fetal heart beat. Often technicians will take the mothers pulse at the same time to check if it is the fetus or the mothers .

HEART RATE M MODE• The very early embryonic heart will be a subtle flicker. This may be measured using M-Mode(avoid Doppler in the first trimester due to risks of bio effects). Initially the heart rate may be slow.

HEART RATE

CROWN RUMP LENGTH (CRL)

• The CRL is a reproducible and accurate method for measuring and dating a fetus.• Early ultra sonographers used this term (CRL) because

early fetuses also adopted the sitting in the chair posture in early pregnancy. After 12 weeks, the accuracy of CRL in predicting gestational age diminishes and is replaced by measurement of the fetal biparietal diameter. • In at least some respects, the term "crown rump length" is

misleading: there is no fetal crown and no fetal rump to measure for most of the first trimester.

CROWN RUMP LENGTH (CRL)

• Until 53 days from the LMP, the most caudad portion of the fetal cell mass is the caudal neuropore, followed by the tail. Only after 53 days is the fetal rump the most caudal portion of the fetus.• Until 60 days from the LMP, the most cephalad portion of

the fetal cell mass is initially the rostral neuropore, and later the cervical flexure.• After 60 days, the fetal head becomes the most cephalad

portion of the fetal cell mass.• What is really measured during this early development of

the fetus is the longest fetal diameter.• From 6 weeks to 9.5 weeks gestational age, the fetal CRL

grows at a rate of about 1 mm per day.

CRL• The Crown Rump Length (CRL) measurement in a 6 week gestation. A mass of fetal cells, separate from the yolk sac, first becomes apparent on transvaginal ultrasound just after the 6th week of gestation. This mass of cells is known as the fetal pole.

CROWN RUMP LENGTH (CRL)

• At 10 weeks, visualize

4 jointed limbs, feet and hands.

CROWN RUMP LENGTH (CRL)

• From 12 weeks the basic morphology of the fetus is visible

NUCHAL TRANSLUCENCY• NUCHAL SONOLUCENCY / FULLNESS / EDEMA• = skin thickening of posterior neck measured between calvarium +dorsal skin margins.• After 13.6 weeks regarded as nuchal fold thickness.• One inner other outer

NUCHAL TRANSLUCENCY• Considered abnormal when• > 0.3 mm during 9-13 weeks MA• >0.5 mm during 14-21 weeks MA• >0.6 mm during 19-24 weeks MA

NUCHAL TRANSLUCENCY• The Nuchal Translucency is used to provide a risk assessment for chromosomal abnormalities, specifically Trisomy 13,18 and 21 (Down's Syndrome).

FETAL LEGS• The legs are usually crossed at the ankles. Confirm the presence and symmetry of the long bones.

FETAL LEGS &FEET• The correct angle the feet to legs can be confirmed. They should be at 90 degrees i.e. perpendicular or Talipes should be suspected.

FETAL UPPER LIMB• The humerus, radius and ulna and the presence of hands are imaged from 11 weeks.

FETAL BRAIN• 12 week choroids take up most of the space within the ventricles.

MULTIPLE GESTATIONS• Twins: 2% of all deliveries-12% of NVD.• Monozygotic 1/250 (1/3 of twins)• Triplets: 1/802

• Quadruplet: 1/803

• Multiple gestations are HIGH RISK pregnancies. • The major problems are:• PRETERM BIRTH

• LOW BIRTH WEIGHT

FETAL TWINNING• Initially twins may be identified as 2 separate gestational

sacs (i.e. diamniotic, dichorionic).• There may be 2 fetal poles within the same gestational sac

(monochorionic).• It is easier to determine chorionicity earlier in the pregnancy

depending on the chorionicity and amnionicity.• It is a sad situation when a "vanishing twin" occurs, which is

about 20% of twin pregnancies. In these cases, one of the twins fails to grow and thrive. Instead, its development arrests and it is reabsorbed, with no evidence at delivery of the twin pregnancy.

MONOCHORIONIC MONOAMNIOTIC TWINS

DICHORIONIC DIAMNIOTIC TWINS.

TRIPLETS• Triplets with 2 sacs. Monoamniotic, monochorionic twins and a normal single.

COMMON ABNORMALITIES• Thickened Nuchal Translucency(NL).• Partial Ovular Detachment.• Retained products of conception.• Anembryonic Gestation.• Gestational trophoblastic disease.• Miscarriage.

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COMMON ABNORMALITIES

• Ectopic Pregnancy.• Subchorionic hemorrhage.• Conjoined Twins.• Antepartum Hemorrhage.• Check heart beat.• Check causes of bleeding.

THICKENED NUCHAL TRANSLUCENCY

• One of the parameters used in sequential screening (SS) for Down’s syndrome in first trimester

– SS: Pregnancy associated plasma protein levels, hCG levels, NT thickness

• Measured during 11-13.6 wks gestational age• Seen on sagittal image as increased subcutaneous non-septated

fluid in posterior fetal neck• Measurement >3mm usually considered abnormal, however

exact cut off measurements are dependent on maternal age/gestational age

• Detection rate of screening for Down’s Syndrome in first trimester:– sequential screening with NT: 82-87% – NT alone: 64-70%.

THICKENED NUCHAL TRANSLUCENCY

THICKENED NUCHAL TRANSLUCENCY

THICKENED NUCHAL TRANSLUCENCY

THICKENED NUCHAL TRANSLUCENCY

THICKENED NUCHAL TRANSLUCENCY

PARTIAL OVULAR DETACHMENT

• The maternal circulation inside the placenta starts peripherally (in the placental margins) and is associated to physiological oxidative phenomena that may lead to membranes rupture and formation.

• The abnormal development of such membranes may result in subchorionic hemorrhage, enhancing the predisposition to an adverse gestational outcome at the third trimester (PPROM and PTL).

• Such abnormality is common and also denominated as subchorionic hemorrhage or trophoblastic hematoma, being visualized in more than 18% of cases of threatened miscarriage.

• The presence of fetal heart activity confers an excellent prognosis. Clinically, subchorionic hemorrhage may course with vaginal bleeding.

PARTIAL OVULAR DETACHMENT

• Sonographic finding of partial ovulation detachment:• Heterogeneous crescent

shape lesion is appreciated adjacent to the gestational sac with gross debris and shows mild compression and deformation.• Fifteen days follow up

demonstrates resolution.

PARTIAL OVULAR DETACHMENT

• Sonographic findings of incomplete decidual fusion.• Anechoic homogeneous collection is seen around GS at 7 and 11 week respectively.

RETAINED PRODUCTS OF CONCEPTION

• RPOCs are characterized by a thickened, disorganized and heterogeneous endometrium, with ill-defined mucosal layers and cavitary line, either with or without the presence of gestational sac. • Clinically, the women presents abdominal pain and relative vaginal bleeding(. • In the presence of an intact gestational sac and closed cervix, the difficulty in a spontaneous resolution will be higher, requiring surgical evacuation

RETAINED PRODUCTS OF CONCEPTION

• Sonographic finding of RPOCs as evidences by heterogeneous ill defined endometrial lined lesion with cystic changes and specks of air.

RETAINED PRODUCTS OF CONCEPTION

RETAINED PRODUCTS OF CONCEPTION

• Transvaginal sonography without (A) and with (B) color Doppler imaging in a case of RPC with endometrial expansion (arrows).

RETAINED PRODUCTS OF CONCEPTION

RETAINED PRODUCTS OF CONCEPTION

EARLY EMBRYO DEATH• Some sonographic findings characterize an embryo death in

the first half of the first trimester in early phases, before the crown-rump length can be measured. • The following aspects are highlighted:

• Small, hyperechoic yolk sac,• Hydropic yolk sac increased in volume with diameter > 7 mm• Even small amniotic cavity disproportionate to the gestational

sac size. • Before the 9th week, small gestational sac may be associated

with aneuploidy.

EARLY EMBRYO DEATH

• Sonographic signs of early embryo death.• A. Intrauterine pregnancy with no sign of embryo, with small, hyperechoic

yolk sac.• B. Monochorionic, diamniotic twin gestation with early death of one of the

embryos (vanishing twin syndrome)

EARLY EMBRYO DEATH

• Sonographic signs of early embryo death.• Small Amniotic cavities

EARLY EMBRYO DEATH

• Sonographic signs of early embryo death.• C. Delayed growth of the gestational sac with disproportionate yolk sac.• D. Hydropic yolk sac and ruptured amniotic sac with floating branches in the

chorionic cavity.

EARLY EMBRYO DEATH

Absent Fetal Cardiac Activity

EARLY EMBRYO DEATH

Absent FCA

ANEMBRYONIC GESTATION• ANEMBRYONIC PREGNANCY= BLIGHTED OVUM• Abnormal intrauterine pregnancy with developmental arrest prior to formation of embryo; may occur as a blighted twin• Empty gestational sac (>6.5 weeks MA)

• yolk sac identified without embryo:• Gestational sac small / appropriate / large for dates:

• decrease in gestational sac (GS) size• GS fails to grow by >0.6 mm/days on serial scans

• Irregular weakly echogenic decidual reaction of <2 mm• Distorted sac shape

ANEMBRYONIC GESTATION• Transabdominal scan:• GS size >10 mm of mean diameter without DDS• GS size >20 mm of mean diameter without yolk sac• GS size >25 mm of mean diameter without embryo

• Transvaginal scan• GS size >8 mm of mean diameter without yolk sac• GS size >16 mm of mean diameter without cardiac activity

ANEMBRYONIC GESTATION

• Sonographic signs of Anembryonic gestation.• A: GS with 12 mm in mean diameter, without yolk sac.• B: One week later, the GS remains without yolk sac.

ANEMBRYONIC GESTATION

BLIGHTED OVUM

ANEMBRYONIC GESTATION

ANEMBRYONIC GESTATION

ANEMBRYONIC GESTATION

GESTATIONAL TROPHOBLASTIC DISEASE

• The typical sonographic finding in most of cases of complete hydatidiform mole is a echogenic, intracavitary solid mass with intermingled, small cystic loci resembling a "snow storm", corresponding to the vesicles that macroscopically characterize this condition.

• The higher the gestational age, the larger the vesicles visualized as homogeneous anechoic images, increasing the method specificity.

• The ultrasonography sensitivity will depend on the gestational age at the moment of the diagnosis.

• Ultrasonography can detect vesicles with > 2 mm in diameter. • In early pregnancies with trophoblastic disease, the sonographic method

accuracy is limited, hindering the differentiation of gestational trophoblastic disease from other conditions involving the endometrial cavity.

PARTIAL HYDATIFORM MOLE

• Partial hydatidiform mole offers higher diagnostic difficulty by ultrasonography.

• In a reasonable number of cases, this disease presents as an empty gestational sac corresponding to anembryonic gestation, or as early embryo death.

• However, two criteria have been described in the literature: gestational sac transverse/anteroposterior diameter ratio > 1,5 and cystic changes, irregularity of increase in echogenicity of decidual/placenta or myometrial reaction

COMPLETE HYDATIFORM MOLE

• Sonographic signs of complete Hydatiform mole. Abdominal and transvaginal US study demonstrates echogenic intracavitary contents with intermingled tiny cystic areas.

PARTIAL HYDATIFORM MOLE

• Partial Hydatiform mole. Thick, irregular trophoblast, with sonographic signs suggesting anembryonic gestation. H/P study demonstrated the presence of molar tissue in the evacuation material.

PARTIAL HYDATIFORM MOLE

• Sonographic signs of partial Hydatiform mole. Focal thickening of the placental bed with predominance of cystic areas and irregularity. Embryo and embryonic remains (arrow) can be visualized.

COMPLETE HYDATIFORM MOLE

Sonographic signs of arteriovenous malformation associated with complete Hydatiform mole. Large anechoic homogeneous myometrial lacuna with vascular map showing fistula pattern and low resistivity flow velocity wave.

ECTOPIC PREGNANCY• Sonographic findings of ectopic pregnancy will vary as a function of

the gestational age and site. • Classically:

• Tubal ring sign • Adnexal disorganized mass molded to the adnexa and/or cul de sac• Solid, organized mass with regular margins mimicking a pediculated

myomatous nodule,• clinically progressing with low β-hCG levels, • presence of a live extra uterine conceptus.

• Uncommon gestational sites may be observed such as abdominal ectopic pregnancy, cervical ectopic pregnancy and ectopic pregnancy in a previous Cesarean section pregnancy.

ECTOPIC PREGNANCY• Sonographic findings of

ectopic pregnancy.• A: Tubal ring sign

(gestational sac in the adnexa).• B: Adenexal mass

ECTOPIC PREGNANCYSonographic finding of ectopic pregnancy. Solid, isoechoic adnexal mass mimicking a pediculated myomatous nodule

ECTOPIC PREGNANCY• Uncommon sites of ectopic pregnancy.• A: GS implanted in cervical region.• B: GS implanted on a previous cesarean section scar.

HETEROTOPIC PREGNANCY

CERVICAL ECTOPIC PREGNANCY

• GS within cervix.• Abnormally low sac position.• On color Doppler : hypertrophic trophoblastic ring in the cervical region.

CERVICAL ECTOPIC PREGNANCY

INTERSTITIAL ECTOPIC PREGNANCY

• Eccentric gestational sac: the diagnosis is suggested by visualization of an intrauterine GS or decidual reaction located high in the fundus, that is surrounded by less than 5 mm of myometrium in all planes.

• Interstitial line sign: an echogenic line from the mass to the endometrial echo.

INTERSTITIAL ECTOPIC PREGNANCY

• Transvaginal ultrasonography reveals, (a) an eccentrically located round ring-like mass (black arrow) in the left uterine fundus. Note the thin echogenic endometrial stripe (white arrow) which extends to the inner margin of this mass, (b) It is incompletely surrounded by myometrium and is compatible with a corneal pregnancy. This measures approximately 2.6 × 2.6 cm and (c) demonstrates peripheral blood flow on color Doppler interrogation.

CESAREAN SCAR ECTOPIC PREGNANCY

• Empty uterus• Empty cervical canal• GS in the anterior part of the lower uterine segment• Absence of myometrium between the bladder wall and the GS.

CESAREAN SCAR ECTOPIC PREGNANCY

• 36-year-old pregnant female presenting with heavy vaginal bleeding for 3 days that slowed to occasional spotting. Patient had a history of two cesarean sections and was later diagnosed with ectopic cesarean pregnancy. (a-c) Transabdominal and transvaginal ultrasonography images reveal (a) a viable gestational sac at the site of previous cesarean scar (black arrow) with a gestational age of 8 weeks 5 days. (b and c) images show the gestational sac is in the lower uterine segment, just superior to the cervix and intimately related to the scar anteriorly (white arrows), Continued

CESAREAN SCAR ECTOPIC PREGNANCY

• MRI d) T2 axial view, (e) T2 sagital view and (f) contrast-enhanced images demonstrate trophoblastic tissue/developing placenta inferiorly with little or no surrounding myometrium (white arrow) confirming scar pregnancy There is some mass effect on the superior aspect of the urinary bladder on the right; however, it does not appear to invade the bladder wall.

SUBCHORIONIC HEMORRHAGE (SCH)

• Occurs when there is perigestational hemorrhage and blood collects between the uterine wall and the chorionic membrane in pregnancy. It is a frequent cause of first and second trimester bleeding.

• Epidemiology• It typically occurs within the first 20 weeks of gestation. If seen in the

first 10-14 days of gestation, they are also sometimes termed implantation bleeds.

SUBCHORIONIC HEMORRHAGE (SCH)

• Crescentic collection with elevation of the chorionic membrane• Depending on the time elapsed since bleeding, the collection will have variable echotexture• Acute: hyperechoic and may be difficult to differentiate

from adjacent chorion• Subacute-chronic: decreasing echogenicity with time

• In almost all cases there is extension of the hematoma towards the margin of the placenta.

SUBCHORIONIC HEMORRHAGE (SCH)

First trimester SCH (subchorionic bleed).

SUBCHORIONIC HEMORRHAGE (SCH)

SUBCHORIONIC HEMORRHAGE (SCH)

SUBCHORIONIC HEMORRHAGE (SCH)

SUBCHORIONIC HEMORRHAGE (SCH)

SUBCHORIONIC HEMORRHAGE (SCH)

SUBCHORIONIC HEMORRHAGE (SCH)

SUBCHORIONIC HEMORRHAGE (SCH)

CONJOINED TWINS• Conjoined twins are a rare and complex complication of

monozygotic twinning, which is associated with high perinatal mortality. • Early prenatal diagnosis of conjoined twins allows better

counselling of the parents regarding the management options, including continuation of pregnancy with post-natal surgery, termination of pregnancy or selective fetocide in case of a triplet pregnancy. • With the introduction of high-resolution and transvaginal

ultrasound imaging, accurate prenatal diagnosis of conjoined twins is possible early in pregnancy.

CONJOINED TWINS• Although first-trimester diagnosis of conjoined twins is

feasible, false-positive cases are common before 10 weeks because, earlier in gestation, fetal movements are limited and monoamniotic twins may appear conjoined. • As most parents opt for immediate termination of

pregnancy at confirmation of the diagnosis, there are limited data on the prenatal follow-up of conjoined twins. • Detailed analysis of case reports where 3D imaging was

used indicates that this modality does not improve on the diagnosis made by 2D ultrasound. Overall, very early prenatal diagnosis and first-trimester 3D imaging provide very little additional practical medical information compared to the 11-14 weeks' ultrasound examination.

CONJOINED TWINS

• Images of the conjoined twins, there are two heads with conjoined body.

CONJOINED TWINS

CONJOINED TWINS• Conjoined twins.

Ultrasound images of fetuses joined at the pelvis and chest, with separate heads.

CONJOINED TWINS

• Three-dimensional sonogram showing the conjoined twins of the thoraco-omphalopagus type.

FIRST TRIMESTER: BLEEDING/MISCARRIAGE, MOLAR CHANGES.

• Miscarriage is defined as the loss of a pregnancy prior to the completion of 24 weeks (Age of viability) gestation and the main maternal symptoms are bleeding and pain. If a fetal HR has been detected, the risk of spontaneous miscarriage in singletons is 12.2%.

FIRST TRIMESTER: BLEEDING/MISCARRIAGE, MOLAR CHANGES.

FIRST TRIMESTER: BLEEDING/MISCARRIAGE, MOLAR CHANGES.

FIRST TRIMESTER: BLEEDING/MISCARRIAGE, MOLAR CHANGES.

TAKE HOME MESSAGE• First trimester US especially TVS is an integral part for

confirmation of intrauterine pregnancy and to rule out ectopic pregnancy.• First trimester US helps us in suggesting conceptus

viability.• First trimester US especially TVS is very efficient in

approaching and evaluating the cause of vaginal bleeding.

Thank You.