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Radiology Conference First Trimester Bleeding

Radiology Conference First Trimester Bleeding. Cliff Erickson M.D. & Praveen Reddy, M.D. Albany Medical Center. 1st Trimester. The interval between the last menstrual period (LMP) and 12 weeks gestation. Early Embryogenesis. Ultrasound. Transabdominal less invasive

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Radiology Conference First Trimester Bleeding

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  1. Radiology Conference First Trimester Bleeding Cliff Erickson M.D. & Praveen Reddy, M.D. Albany Medical Center

  2. 1st Trimester • The interval between the last menstrual period (LMP) and 12 weeks gestation

  3. Early Embryogenesis

  4. Ultrasound • Transabdominal • less invasive • wider view of pelvic structures • bladder needs to be full • probe is lower frequency so have lower resolution • Transvaginal • invasive • bladder does not need to be full • higher frequency probe so better resolution • can evaluate in different planes

  5. Definitions • Echogenic - degree to which a structure deflects ultrasound beams. • Anechoic - (or hypoechoic) structures that transmit rather than deflect ultrasound beams and appear black such as water and blood. • Increased echogenecity - appears white like gas, stones, fat and bones.

  6. Normal Uterus

  7. Normal Ovary

  8. Cul-de-Sac Fluid

  9. Gestational Sac

  10. Double-bleb Sign

  11. Yolk Sac

  12. Double Decidual Sac Sign

  13. Embryo

  14. Case #1 • 22 yo female presents to the ED with c/o vaginal bleeding. The patient denies abdominal pain. • What do you want to know now? • Sexually active, LMP 7 weeks ago • No prior pregnancies • No hx STD/ abnormal gyn exams • What is the next test? • ICON+

  15. Case #1 Differential Diagnosis • Threatened or spontaneous abortion • Ectopic pregnancy • Normal ovum implantation • occurs around time of expected menses • Subchorionic hemmorhage • Gestational trophoblastic disease • 1:1700 pregnacies

  16. U/S findings of a normal IUP • Identification of a gestational sac with yolk sac or fetal pole confirms IUP • Excludes diagnosis of ectopic pregnancy except if you have a heterotopic pregnancy. Incidence in past was 1/30,000. Now ranges from 1/3,000 to 1/6,000.

  17. IUP with Subchorionic hemorrhage

  18. Subchorionic hemorrhage

  19. Spontaneous Abortion • Loss of pregnancy before 20 weeks/500g • 20-40% of pregnancies • 75% in first 8 weeks • 50-60% due to chromosomal abnormalities • Multiple risk factors • age - • prior SAB • comorbidities • maternal infections

  20. Spontaneous Abortion • Threatened: bleeding, os closed • 50-80% miscarry • Inevitable: bleeding, os open • Incomplete: bleeding, os open, passage of poc • most likely between 6-14 weeks • Complete: bleeding stopped, os closed, poc expelled. • difficult to diagnose in ED

  21. Early Failure • No embryonic cardiac activity with CRL > 5 mm • Embryonic bradycardia relative to CRL. • 100% if CRL < 5 mm and rate is less than 80 bpm or with CRL of 5 - 9 mm and rate < 100 bpm, and CRL 10 - 15 mm with rate < 110 pm. • Gestational sac > 8 mm without a yolk sac • Gestational sac > 16 mm without an embryo • Mean sac diameter minus CRL is less than 5 mm • Poor sac growth. • normally grows 1 mm mean sac diameter per day. • Large yolk sac (> 5.6 mm prior to 10 weeks) • Abnormally large or floppy, amniotic sac

  22. Large Gestational Sac

  23. Normal embryo with small gestational sac

  24. Case # 2 • 25 yo female G3 P1011 with a history of ETOP and PID in the past presents with left sided pelvic pain for two days and intermittent vaginal spotting. • VS P 74 BP 123/72 RR 14 • DDx?

  25. Ectopic Pregnancy: Epidemiology • ~2% of pregnancies • ~40% are missed in first encounter • 4-5x increase in rates over last 20 years • Leading cause of maternal 1st trimester death • second overall to PE • death rate decreased from 35.5/10000 in 1970 to 3.8/10000 in 1989 • nonwhite women have 3.4x increased death rate • teenagers have highest death rate

  26. Ectopic Pregnancy: Risk Factors • History of PID • increases risk 6-7x • each subsequent episode further increases risk • History of prior ectopic pregnancy • Tubal ligation • ectopic until proven otherwise • IUD use • 3-4% of pregnancies with IUD • not type specific • does not continue past removal of IUD

  27. Ectopic Pregnancy: Risk Factors • History of gynecological surgery • ETOP • Prior diagnosis of adhesions • IVF • Chemical ovulation induction • Other assisted reproduction techniques

  28. Ectopic Pregnancy: Risk Factors 50% of patients with an ectopic pregnancy have NO risk factors

  29. Ectopic Pregnancy: History • Menstrual history • amenorrhea 4-12 weeks in 70% cases • 15% of patients report no missed menses • no predictive value • Abdominal pain • “classic” rupture localized, sharp, severe, sudden • 10% may have no pain with EP • 20% with rupture reported shoulder pain • 4% with rupture are pain free

  30. Ectopic Pregnancy: History • Vaginal bleeding • 80% of EP have VB • typically scant/spotting • heavy bleeding suggests SAB but does not rule out ectopic • bleeding usually precedes pain

  31. Ectopic Pregnancy: Physical Exam • Highly variable • Peritoneal signs are present in ~90% of ruptures • Shock, adnexal mass and tenderness “classic” • Fever is rare <2% • Adnexal mass or fullness 65% of patients • 20% on opposite side from EP (corpus luteum cyst) • May have CMT • May have a normal exam

  32. Ectopic Pregnancy: H & P There is no way to exclude ectopic pregnancy on the basis of history and physical examination.

  33. Ectopic Pregnancy Treatment • Medical • methotrexate most common choice • generally useful <6 weeks EGA & <3.5 cm • 5-10% treatment failures • abd pain 3-7 d post administration in 35-55% of pts • Surgical • laparotomy vs laparoscopy • laparoscopic salpingostomy maximizes fertility

  34. Extrauterine Gestation • 95 - 97 % Tubal • 0.5 - 1% Ovary • 0.1 % Cervix

  35. EGA and B-hCG levels • Limited to IUPs only • Doubles every 2 days EGA B-hCG U/S findings 5 weeks 1000 gestational sac 6 weeks 2500 yolk sac 7 weeks 5000 fetal pole 8 weeks 17000 fetal heart beat

  36. Ectopic Pregnancy: Sonographic Findings • Empty nongravid uterus with… • A live embryo in the adnexa • An adnexal mass with a tubal ring (gestational sac) +/- yolk sac • An adnexal mass with no definite tubal ring • Echogenic free fluid • Decidual cyst

  37. Sonographic Findings and Risk of Ectopic T/A Endovaginal Adnexal Embryo 100 100 Mass and large to moderate amount of fluid 100 100 Mass and Fluid 85 78 Any Fluid 71 75 Any Mass 71 69 No mass or Fluid 20 33

  38. Adnexal embryo with heart beat Adnexal mass with yolk sac or embryo Adnexal mass with tubal ring Any adnexal mass, not a simple cyst Decidual cyst 100% 100% 97.8% 96.3% 80% PPV of U/S findings for an ectopic pregnancy

  39. Live embryo in adnexa

  40. Left adnexal tubal pregnancy

  41. Psuedogestational sac

  42. Psuedogestational sac

  43. Decidual Crest

  44. Decidual cast

  45. Decidual cast with adnexal mass

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