1st Trimester abnormalities

Subchorionic hemorrhage

Bleeding between the UT wall and chorion

Can lead to spontaneous abortion

Usually diagnosed after 9 weeks

Subchorionic hemorrhage usually causes:

Bright red spotting due to fresh bleeding in affected area

Subchorionic hemorrhage USA

Hypoechoic structure between chorion and UT wall

Usually crescent shaped

May see debris with thrombus formation within

Subchorionic hemorrhage

Risk factors of ectopic

Hx of PID, fertility treatment, tubal surgery, previous ectopic, DES exposure

IUD device

#1 risk for ectopic

Tubal surgery/trauma

Most common location for ectopic

Ampulla

Locations for ectopic

Throughout fallopian tube

C-section scar

Cervix (hourglass shaped UT)

Ovary

Abdomen

Retroperitoneal

Angular pregnancy

An ectopic pregnancy that implants at the upper lateral corner of the endo cavity near the opening of the fallopian tube

Ectopic usually occurs on the ____ side as corpus luteum

Same

Highest risk for complications occur if ectopic is located in the _______ portion of the fallopian tube

Interstitial

Classic triad of ectopic symptoms

Missed period, pain, irregular vaginal bleeding

Symptoms of ectopic rupture

They vary

Shoulder pain

Vertigo

Syncope

Shock

Methotrexate used to treat early unruptured ectopic causes:

Involution of ectopic and preserves fertility of pt

Indirect signs of ectopic pregnancy

FF in cul-de-sac or Morrisons pouch

Empty GS in uterus with no yolk sac

Pseudosac with one decidual layer (IUP has 2)

USA ectopic pregnancy

Complex adnexal mass located between ovary and UT

Fetal heart motion may be seen

Adnexal tubal ring (bagel or donut sign)

RING OF FIRE (increased vascularity surrounding decidual reaction)

Ectopic

C-section ectopic

Hydatidiform Mole

GTD

Hyperplasia and overgrowth of trophoblastic material

Fertilization occurs without chromosomes present

80% are benign

HIGH levels of hCG → nausea and hyperemesis

String indicator of molar pregnancy

Acute onset of maternal systemic HTN in first trimester

Moles are caused by

Excessive paternal genetic material = two sperm fettilize a single egg

Moles are associated with

Theca lutein cyst and enlarged UT for gestational age

Complete mole

MOST COMMON
No fetus

Severely increased hCG

May be seen with theca lutein cyst

Enlarged uterus with heterogeneous endo cavity, SNOWSTORM appearance

Hydropic villi appear as multiple cystic structures within the uterine cavity

Partial mole

Fetus and molar pregnancy; can occur with an abnormal or normal fetus

If abnormal, most fetuses are triploid (2 sperm, 1 egg = 3 copies of all)

Area of heterogeneous molar tissue Adjacent to fetus

Placenta >4cm AP at 18-22 weeks

Partial molar pregnancy

Complete molar pregnancy

Chorioadenoma Destruens

Persistent trophoblastic neoplasm

Invasive malignant molar pregnancy that moves into myometrium, uterine wall and PERITONEUM

Very invasive but specific to uterus

Pelvic nodes are normal and liver is clear

Heterogeneous with vascularity

Chorioadenoma destruens

Choriocarcinoma

Persistent trophoblastic neoplasm

Malignant molar pregnancy that mets to liver

Abnormal pelvic lymph nodes

Elevated hCG levels in a non pregnant female

May see masses in cervix and vaginA

Highly vascular complex mass

Most common solid mass found with pregnancy

Fibroids

Submucosal fibroids have highest risk for …

Early pregnancy complications

Cervical fibroids have highest risk for…

Delivery complications

Major anomalies easily identified in 1st tri

Acrania, anencephaly, alobar holoprosencephaly, body stalk anomaly, ectopia cordis, megacystitis, omphalocele, gastroschisis

NT

11-14wks

Midsagittal plane

Neck in neutral position

3 echogenic lines should be demonstrated (inner and outer borders of skin and amnion)

>3mm = abnormal

Abnormal NT/NSF = Trisomy 21 (80%)

Use largest measurement

Nuchal skin fold >__mm is abnormal, measured in 15-21 weeks

6

Alobar holoprosencephaly

SINGLE ventricle, fused thalami, absent CC

Cephalocele

Bony defect with intracranial contents protruding

Ventriculomegaly

Dilated lateral ventricles with dangling choroid plexus

Dandy walker malformation

Enlarged IT space, compressed brainstem, large posterior fossa

Omphalocele

Midline wall defect with viscera covered by membrane, can contain intestines, liver and stomach

Gastroschisis

Wall defect adjacent to cord insertion, herniated bowel NOT covered by membrane

Increased AFP

Pentalogy of Cantrell

1. Midline supraumbilical wall defect

2. Diaphragmatic hernia

3. Defect of distal sternum

4. Defect in pericardium

5. Intracardiac defect/ectopia cordis

Ectopia cordis

Sternal defect with heart protruding out of chest

Limb body wall complex

Large wall defect, short/no umbilical cord with fetus fixed to placenta

Bladder exstrophy

Wall defect below cord insertion, bladder protrudes outside body

Malposition of heart

Heart in mid or right chest

Abnormal cardiac axis

Normal axis is 45 degrees from midline, rotation from this axis is abnormal

Diaphragmatic hernia

Stomach and/or liver in chest cavity

Lung agenesis or hypoplasia

Absence of echogenic lung tissue surrounding the heart, smaller thoracic circumference, cardiac malposition

Anencephaly

1 of most common NTD (spina bifida is other)

Failure of neurulation defect

Cephalic end of neural tube fails to close

Absence of upper cranial vault and cerebral tissue

Seen as early as 12 weeks

Increased AFP

Fetal demise

FROGGY EYES

Acrania

Or exencephaly

Lack of cranial bone formation

Cerebral tissues form but in abnormal fashion

Brain tissues droop to sides - MICKEY MOUSE SIGN

Seen as early as 12 weeks

Increased AFP

Spina bifida that can be identified in first trimester

Open spina bifida

Spina bifida first trimester diagnosis relies on …

Documentation of compression of choroid, intracranial translucency, and CM with enlarged brainstem

Spina bifida

Changes occur due to posterior shift of cranial contents

Typical banana and lemon sign not well demonstrated first tri b/c cerebellum is not formed and cranium is not fully ossified

Eval of skin line can demonstrate defect

Frontomaxillary angle is narrow in first trimester cases of open defects

Bladder exstrophy

Encephalocele

Alobar holoprosencephaly

Pentalogy of Cantrell

Aneuploidy

Increased NT thickness

Abnormal bhCG and PAPP-A

Eval nasal bone, face, mandible, post fossa, NT, lungs, heart, stomach, kidneys

CVS is recommended with abnormal US

Trisomy 21

Increased NT thickness

Serum bhCG levels are elevated

Serum PAPP-A levels are decreased

Other Markers:

• Hypoplasia/absence of nasal bone

• AVSD

• Tricuspid regurgitation

• Echogenic cardiac focus

• Retrograde A-wave of ductus venosus

Trisomy 13

Increased NT

Decreased bhCG and PAPP-A

Alobar holoprosencephaly

Midline facial anomalies

Megacyctitis

Severe hydrops

Tricuspid regurgitation

Retrograde A wave on ductus venosus

Trisomy 18

Largest NT thickness of T21, 13 and 18

Decreased bhCH and PAPP-A

Hypoplasia/absence of nasal bone

Dilated 4th ventricle and post fossa

CP cysts

Spina bifida

Omphalocele

Diaphragmatic hernia

Severe hydrops

Tricuspid regurgitation

Retrograde A wave on ductus venosus

Turner syndrome (monosomy X)

Sex gene syndrome 45X0

Markedly thickened NT → Cystic hygroma

Serum bhCG are normal, PAPP-A are decreased

Normal nasal bone

Tachycardia

Hypoplastic left heart

Hydrops

Renal anomalies

Tricuspid regurgitation

Retrograde A wave on ductus venosus

Triploidy

Complete extra set of chromosomes

Extra paternal chromosome - Diandric triploidy

Increased NT thickness

Serum bhCG are normal and decreased PAPP-A

Normal CRL or short

Molar placenta

Extra maternal chromosomes

Large head, small abdomen

Small placenta

Echogenic bowel

Spina bifida

Most common method for assessing bhCG

Urinalysis

Most common cause of fetal demise in first trimester

Chromosomal abnormalities

__________ is most commonly associated with molar pregnancy

Preeclampsia

A triploidy fetus is commonly associated with ______ molar pregnancy

Partial

An ectopic that implants at the upper lateral corner of the endo cavity near the opening to the fallopian tube is called:

Angular

In a partial molar pregnancy the accompanying fetus typically has what chromosomal anomaly?

3 copies of all chromosomes

Optimal vies for NT measurement

Midsagittal plane that demonstrates echogenic tip of nose, rectangular palate, translucent diencephalon and NT

First trimester diagnosis of spina bifida relies on documentation of:

Compression of choroid, intracranial translucency, CM with enlarged brainstem

What doppler finding in the first trimester pregnancy is suggestive of aneuploidy

Retrograde A-wave of ductus venosus