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EARLY PREGNANCY PITFALLSDr Catherine Magee
Clinical Fellow
Guys and St. Thomas’ NHS
Foundation Trust
CONTENTS
Why / who / when should we scan?
Role of biochemical markers
Scan findings:
Pregnancy of Unknown Location
Ectopic pregnancies
Miscarriage
Difficulties in diagnosis
SCANNING IN THE EARLY PREGNANCY UNIT
Why
Determine the location and viability of a pregnancy
Who
Symptomatic
Reassurance scan
Dating scan
Post miscarriage / termination
When
At presentation
Positive urinary pregnancy test
No need for blood HCG / progesterone prior to scan
BIOCHEMICAL MARKERS
BHCG
Hormone produced by the placental trophoblast
Detected in plasma or urine 8 days post ovulation
Peaks at 8-10 weeks gestation
Trend gives indication of pregnancy viability
Typically doubles over 48 hours in viable intrauterine pregnancies
Not used to establish gestational age
Not used to diagnose location of pregnancy
Used to plan management of ectopic pregnancy
BIOCHEMICAL MARKERS
Progesterone
Hormone produced by ovaries
Causes endometrial lining to thicken after ovulation
Continued production by corpus luteum after fertilisation / implantation
Usually high in viable intrauterine pregnancies, low in failing pregnancies
Not useful in predicting ectopic pregnancies
No need for serial progesterone levels
WHEN SHOULD WE SCAN?
Discriminatory zone for intrauterine pregnancies
Not the case for ectopic pregnancies
Therefore don’t need bloods prior to first scan
PREGNANCY OF UNKNOWN LOCATION
Positive pregnancy test but unable to visualise pregnancy on ultrasound
Pregnancy site not visualised on between 8-31% of scans
Three eventual possibilities:
Viable IUP
Failing pregnancy / miscarriage
Ectopic pregnancy
PUL
Symptoms
Scan findings
Blood in pelvis
Tenderness on scanning
Endometrial thickness
Gestation
Assisted conception
Unknown dates
Irregular cycle
PUL
Must have BHCG and progesterone levels
Follow up as per results
Algorithms
ECTOPIC PREGNANCIES
Pregnancy implanted anywhere outside the endometrial cavity
Most commonly tubal
Incidence 11/1000 pregnancies in UK
2-3% of women presenting to Early Pregnancy Unit
Known risk factors
DIFFICULTIES WITH ECTOPIC PREGNANCIES
Often present with vague / atypical symptoms
Majority will not have known risk factor
Can have with low HCG
If a patient has ‘passed tissue’ – does not rule out ectopic
Endometrium can be of varying thickness
Pseudosac can mimic early gestation sac
Can have other adnexal masses with different pathology
Cervical ectopics can mimic miscarriage
ENDOMETRIAL THICKNESS
EARLY GESTATIONAL SAC VS PSEUDOSAC
Anechoic sac with trophoblastic reaction
Eccentrically located
Blood flow when Colour Doppler applied
Negative sliding sign
Intradecidual sign
Double decidual sign
Irregular
Centrally located in endometrial cavity
Also consider decidual cysts
WHICH ARE EARLY GESTATIONAL SACS?
ADNEXAL MASS
CERVICAL ECTOPIC
Cervical pregnancies are rare, accounting for less than 1% of all ectopic gestations.
Ultrasound criteria for diagnosis
Empty uterine cavity.
A barrel-shaped cervix.
A gestational sac present below the level of the internal cervical os.
The absence of the ‘sliding sign’.
Blood flow around the gestational sac using colour Doppler
CERVICAL ECTOPIC VS. MISCARRIAGE
THE CORPUS LUTEUM
Cyst like structure on ovary
Different appearances / sizes
Hypoechoic cyst
Solid
Haemorrhagic
Classic ‘ring of fire’ when Doppler applied
Can be bilateral
Twin / heterotopic pregnancy
Note also number of embryos transferred
MISCARRIAGE
Delayed / missed
Empty sac with MSD >25.0mm
CRL with no FH >7.0mm
If CRL <7mm with no FH, must repeat TV US in 7 days
Always offer 2nd opinion
Should diagnose on transvaginal scan
If TA scan must have repeat in 14 days
Incomplete / Retained products of conception
Complete
DIAGNOSING MISCARRIAGE
Differences in intra- and inter-observer measurements
2011 study by Pexters et. al
18.8% difference in measurements of gestational sac (inter-observer)
14.6% difference in measurements of CRL (inter-observer)
11.4% difference in measurements of CRL (intra-observer)
Guidelines changed in 2011 to be 100% specific for the diagnosis of miscarriage ie. larger CRL and GS measurements
OTHER DIFFICULTIES
Chorionic bumps
Fibroids
Adenomyosis
Uterine anomalies
COMPLETE MISCARRIAGE?
History of heavy PVB with thin endometrium
Approx 5% of these will actually have ectopic pregnancy
If the first scan, always clarify with biochemical markers and follow up
CONCLUSIONS
Ultrasound is gold standard for diagnosis in early pregnancy
Early Pregnancy Unit is a multi disciplinary team
Be aware of difficulties
If in doubt – 2nd opinion or wait and rescan