First Trimester Bleeding - SD

Introduction

I'm Vic Dogra from University of Rochester, New York.

I am the associate chair for research and education and also director of ultrasound.

Today, I'll be presenting first trimester bleeding, which is very important in day-to-day practice.

I'm gonna present first trimester bleeding in coming about 30 minutes or so before we can proceed to understand what is a first trimester bleeding.

Normal Gestation

It's very important to know about the normal gestation and a gest sac should be identified with the TRANSVAAL examination approximately with 2000 international units of beta cg and with the transabdominal sonogram at about 6,500 international units of beta cg.

A sub normal increase in the serum beta CG in early pregnancy, less than 66% in 48 hours suggest the pregnancy is not viable and progess concentration greater than 25 nanogram is suggestive of a interuterine pregnancy in most cases.

And a level below five nanogram indicates a non-viable pregnancy.

Just sac is usually visible at about five weeks.

When you see sac and a yolk sac, that means that the pregnancy is about 5.5 weeks.

And when you see embryo with the above two, it's six weeks.

And at a five millimeter of CRL length, that is crowned rum length, the cardiac activity should be present and one should measure the CR length at seven millimeter.

I must clarify that GE in sac is not an embryological term.

It is a ultrasound term, which simply means an extra Islamic cavity when you see it by a sonogram.

We call it gestational sac.

This is a great example showing the double des sac sign where you can see that there is an embryo within the calipers, which is surrounded by a nice amniotic cavity.

And there is this double onic activity, which is the decidua capsularis, and you have decidua peris at this level.

And if it is meant of the endometrial cavity and you have a corresponding diagrammatic representation of the same, sometimes the al reaction can be very severe and one should not mistake this for the mole.

It's very important to follow these cases with a few weeks of interval.

And this is one such example where you find that there was a marked in reaction, however, it subsequently proved to be intrauterine pregnancy and patient delivered a normal healthy baby yac is a different sign of intrauterine pregnancy, and it's very important that one should call that inter pregnancy is present only when the yolk sac is seen and not at the presence of simply alsac.

Spontaneous Abortion

Now, ponent is abortion is the biggest category which accounts for the majority of cases of patients who presented with bleeding in first trimester.

And it is defined as a pregnancy which terminates before the completion of about 20th week of gestation.

And as you can see, that 70% of spinal is abortions are due to genetic abnormalities.

Of course trisomy is the major culprit in this and half and about 65% of spontaneous abortions occur before the 60 weeks of gestation.

Now, if you are into classification of pon is abortion, you can classify them into third abortion, incomplete abortion, missed abortion, complete abortion, and inevitable abortion.

I'm not going to go into the details as they are self evident on the slide, and I would encourage the audience to read through it, but I certainly wanna draw an attention that you can see a solo gest sac in a ectopic pregnancy.

And the way to differentiate that from a true gestational sac is that the intra pregnancy has an eccentric location within the endometrial cavity, as you can see in this.

And you can see that the endometrial cavity is right here, which is the phase.

And in this you can see that this is right in the center of the endometrial cavity with a lot of ular cast.

And this is of course a no brainer to differentiate between the true and the s registrational sac, which you may see in ectopic pregnancy.

This is just to highlight that the true just geal sac has a hyper coic wall, and that is because of the surrounding Corona VII and de reaction.

Ultrasound Features of Pregnancy Failure

Now, the transversal ultrasound features of pregnancy failure are very important to understand.

And as you can see given this slide, when you have an absence of intrans sac with serum beta C level above the discriminatory level of 1000, you need to exclude the presence of an ectopic pregnancy.

Similarly, I'm sure the audience can go through this slide and see that the embryo of high millimeter and above if you have no cardiac activity you know that this corresponds to embryonic demise.

This is a great example of an Embry pregnancy where you can see that gestational sac is very large, it's slightly irregular, and there is no evidence of Embry pole or a yolk sac.

This is an example of an abnormal gestational sac.

You can see that the sac is irregular in appearance.

It's irregular in appearance, and there is no embryo or yolk sac.

So this is an abnormal sac suggesting that the patient has a non-viable intrauterine pregnancy.

Now, this is a very good example.

Sometimes you may see abortion in progress.

This is one such example.

You can see a**l cavity within this arrowhead, where you can see that there is some distal cast and some hemorrhage within the endometrial cavity, but the just no sac has been dislodged.

And on the way out, however, these two examples are not the abortion progress.

This is an example of the cervical pregnancy.

Here you can see a nice endometrial cavity.

This is a cervical canal, and you can see that the atropic pregnancy is implanted at the level of the cervix.

And the way to differentiate these two is what is called a sliding sign.

If you put the endovascular probe and you try to push this, you'll be able to slide this GEs sac, but you'll not be able to slide these two.

And if you put color flow doppler, you would see a lot of activity.

And of course, on real time, you'll see cardiac activity that confirms that this to be cervical pregnancy.

This is another example of abortion progress.

You can see this just sac is low lying and is on way to be expelled from the cervix.

And in this case, you can see in transabdominal sonogram, this is a cervical pregnancy.

This is the vagina.

And here you can see on transvaginal sonogram, there's a big large live embryo at the level of the cervix.

Subchorionic Hemorrhage

This is a good example of a sub chorionic hemorrhage.

You can see that this ge geal sac is irregular.

You have a cast secondary and corona vii, and this is a small subcate hemorrhage.

These cases need to be followed at a regular interval to prove the viability of the fetus.

However, the size of the subcate hemorrhage does not correlate with the survival or non survival of the IUP.

Missed Abortion

This example of a missed abortion, when the concept of the products of conception are retained and are being reabsorbed.

And you can see this embryo is very very small corresponding to this large gestational sac.

Therefore, one knows that this is a mis abortion.

Retained Products of Conception

The other major category that represents with retained with first trimester bleeding is retained products of conception.

And it's very important to differentiate this from other entities.

Now, they typically consist of the retained placental tissue, and on a gray scale, you would see an echogenic mass in the uterine cavity.

However, color flow doppler may help to visualize vascular clarity, but absence of vascular clarity should not dissuade you from making that diagnosis.

This is a great example of al conception.

You can see that the endometrial cavity has a marked hyper echoic appearance on transvaal sono sonogram.

You can see that there are some antique areas.

This is a hyper coic mass with increased vascular clarity, and that is consistent with retained products of conception.

Ectopic Pregnancy

The third major category responsible for the first trimester bleeding is what is called the ectopic pregnancy.

And this is very very important entity for one to understand the cause of the first trimester bleeding.

95% of first ectopic pregnancies occur within the ary or the is stomach portion of the Philipp tube.

And actual mass that contain the yolk sac or viable embryo is certainly a definite proof of an ectopic pregnancy.

However, the commonest thing what one finds is an extra ovarian initial mass is the most common sonographic finding.

And most of the people ask me, what about the ovarian ovarian pregnancy?

Please note that the ovarian pregnancy is extremely rare, and if you find certainly it'll be worth publishing a case report.

Tubal ring sign is the second most common sonographic finding and is seen in the hyper ring around the al sac, and will also demonstrate increased vascular clarity on chlor flow doppler and which can be called a ring of fire.

And that can also be seen in carpo luteal cyst and in many other entities.

Please note that about one third of the opis will have a normal pelvic sonogram on transvaginal sonography.

And you may not say any abnormality.

The uterine findings in ectopic pregnancy include the uterus may be normal cast and suggestional sac and findings.

I just mentioned some in my previous slide and I would encourage my audience to go through this list and also to read through this article as referenced at the bottom.

This is a great example of a tubal ring sign.

You can see this is an ovary because it's a big black hole consistent with the follicle, and you have a large thickened Philippian tube seconded to Corona villa industrial reaction with a sac.

And on color on the post doppler, you can see there's a high flow low resistance and a clear flow.

Doppler reveals adding a fire, and that certainly confirms a lot of increased vascularity, and that is consistent with a ectopic pregnancy.

Nowadays, a lot of people undergo scar.

A lot of people undergo c-section that results in a scar in the lower uterine segment, and sometimes you can have a pregnancy at that level, and that is called the scar pregnancy.

And here on the gray scale, you can see this is the cervix.

This the anterior wall of the lower a part of the uterus showing a scar.

There's a nice implantation within the myometrium.

This is the embryo and this is the amniotic cavity, and this is the vascular clarity in the as well as coronary and VII resulting in place implantation.

Gestational Trophoblastic Disease

The next category, which is very important to understand for the first trimester bleeding is the gestational TRLs disease and how to form mole forms.

The maximum bulk of this entity that can be complete mole or a partial mole, and you can have gestational trophoblastic tumors comprising of the falling tumors, including cyte trophoblastic tumor.

You all are aware of the presentation of the molar pregnancy, and I can only say that.

Please note, this patient is presented with a hypertension before 24 weeks, hyper erum oxys and a passage of grip like vesicles, transvaginally.

You can have an hat if a mole that constitutes about 80% of the cases of the GTT, and there is now accompanying embryo or fetus with this.

And uterine frontal height is usually more than expected for the gestational age.

And serum beta CG levels are markedly elevated in the range of thousands, such as 30 to 40,000 range.

Now, molar changes can be detected from eight weeks of pregnancy.

Snow storm appearance with can be seen with a low frequency transabdominal scanning.

When you use high frequency transvaginal transducers, you would see numerous discrete antiotic spaces secondary to a hydric vii and partial mole.

If you have one, you will always see a tritin embryo along with the molar changes.

Now, thick lutein ovarian cyst, I'm sure you all are aware, occur in about 25 to 60% of cases ovaries enlarged with a multiple cyst having a soap bubble or spoke wheel appearance.

This is a great example of a heart foam, a mole that is complete on sonogram.

You can see that there are multiple cystic areas within the endometrial cavity with hyper coic areas interspersed in between and on Mr.

With gallium enhancement, you can see that the uterine musculature is enhancing and the cystic area show no evidence of enhancement.

And certainly this is well published in past all radiology clinics after 2004.

And I would encourage you to read this, this example of partial mole where you can see placental implantation with yolk sac and embryo.

So this is a mole developing within the placental implantation site.

A lot accompanied to buy a partial with embryo and with yolk sac.

This is consistent with a partial mole.

Now sometimes this you can have an inducive mole, and as you can see that this entity invades the myometrium and shows marked hyperverse clarity, as you can see in this image.

And on MT two images, it looks hyperintense.

This is the normal appearance of the ome cavity, and this is the cervix and bladder is bright ated sequence.

Arteriovenous Malformation of the Uterus

The next category, which I want to discuss with you regarding the first time of bleeding is artery venous malformation of the uterus.

It's not much discussed in most literature.

This malformations are rare but can be life threatening.

They can be conal or acquired conal AVMs have multiple artery venous communications and acquired lesions of artery venous fistula between single artery and a vein.

And vascular malformations persist following the treatment in 10 to 15% of patients with gestational trophoblastic disease.

Now, on a gray scale, you would see multiple anaco spaces with the mosaic pattern of color signal within the Citrix space on a cloud ultrasound.

But this usually is within the myometrium and not in the endometrial cavity, and has a great example.

This young lady presents with spontaneous abortion.

She had a history of actually multiple ponent abortions, and this time she presented with bleeding after ponent abortion.

On a gray scale, you see a hyper coic area on a color flow doppler, you see eccentric mosaic pattern, color flow, other from the endometrial cavity.

And when you put spectral doppler, you see ized blood flow pattern.

And this is of the a VM.

Of course, this patient did undergo mr evaluation and that was confirmed to be a VM and that was treated with qual embolization by the international radiologist.

And subsequently, patient went on to conceive and delivered normal baby.

Ultrasound Approach Algorithm

This is an outlined of the first time as to ultrasound proposed algorithm, how to evaluate women in this.

And this is from GaN AR diagnostic ultrasound.

How do they approach, and this is their algorithm.

I would encourage the readers to follow this.

Conclusion

At this point, I would conclude and say I enjoyed giving this presentation.