1rst Trimester: New Criteria for Failed Pregnancy

Transcription

1 1rst Trimester: New Criteria for Failed Pregnancy Beryl Benacerraf M.D. Harvard Medical School Goals of First Trimester Scan Number and location of gestational sac Cardiac activity Number of embryos, yolk sacs Gestational age Detecting anomalies Evaluation of adnexa, extrauterine masses, fibroids etc 4.5 weeks sac 5.5 weeks 6 weeks heartbeat usually seen Crown- Rump Length 6 12 wks

2 Vaginal Bleeding Normal pregnancy Missed AB or blighted ovum Ectopic pregnancy Complete AB Molar pregnancy Signs of First Trimester Pregnancy Failure Sac with no embryo Embryo 7 mm with no FH Small sac size First trimester bradycardia Yolk sac too big, irregular, or calcified Slow embryo growth Crown-Rump Length at which FH should always be seen Early studies Levi 1990: 4 mm Goldstein 1992:4 mm Brown 1990: 5 mm Pennell 1991: 5 mm 5 mm became the generally accepted cutoff Concerns With the Early Data There are several cases of embryos with CRL 5-6 mm and no FH that subsequently proved to be viable (Abdallah 2011; Hamilton 2011) Interobserver variability of CRL has been found to be ±15% (Pexsters 2011) One practitioner's 6 mm CRL may be 15% higher, or 6.9 mm, when measured by others Crown-Rump Length CRL 7 mm & no heartbeat: definitive for failed pregnancy CRL < 7 mm & no heartbeat: suspicious for failed pregnancy Doubilet et al. N Engl J Med 2013; 369:1443 Mean Sac Diameter above which an embryo should be consistently visible Early studies Levi 1988: 16 mm Tongsong 1994: 17 mm 16 mm became the generally accepted cutoff

3 Concerns With the Early Data There are several cases of embryos with MSD of mm and no FH that subsequently proved to be viable (Abdallah 2011; Rowling 1997) Interobserver variability of MSD has been found to be ±19% (Pexsters 2011) ü One practitioner's 21 mm MSD may be 19% higher, or 25.0 mm, when measured by others Mean Sac Diameter MSD 25 mm & no embryo: definitive for failed pregnancy MSD mm & no embryo: suspicious for failed pregnancy Doubilet et al. N Engl J Med 2013; 369:1443 Time-Based Criteria for Definitive Pregnancy Failure Scan 1 Scan 2 Gestational 2 weeks No sac no YS embryo Time-Based Criteria Definite Pregnancy Failure 16 days Gestational sac with YS 11 days No embryo Gestational sac with YS 11 days No embryo Other Criteria Suspicious for Pregnancy Failure Empty amnion Amnion adjacent to yolk sac, no embryo Large yolk sac (>7 mm) Small gestational sac size (MSD CRL < 5 mm) Signs of failing pregnancy Large empty sac > 7mm Pole - no FH Large yolk sac Small Gest. Sac Early bradycardia Empty amnion

4 Signs of failing pregnancy FIRST TRIMESTER BRADYCARDIA 165 Large empty sac > 7mm Pole - no FH Large yolk sac Small Gest. Sac Early bradycardia Empty amnion HEART RATE (bpm) Viable at 12 w SAB 10 GESTATIONAL AGE (weeks) Small sac size Large Yolk Sac Visible Amnion Subchorionic Hematoma

5 Subchorionic Hematoma Subchorionic Hematoma Scans of 516 pts with vaginal bleeding, a live fetus and subchorionic hematoma were retrospectively reviewed. Hematoma size was graded according to % of chorionic sac elevated by hematoma ( <1/3, 1/3-1/2, > 2/3). Patients were classified by GA(< 8 weeks,> 8 weeks) and maternal age (< 35 years, > 35 years). Results - Chorionic Hematoma The overall spont. abortion rate was 9.3%. The rate doubled when the separation was large (18.8%) vs. small and moderate (7.7% and 9.2%). The SAB rate was 2X as high for women age 35 vs. younger women (13.8% and 7.3%), and for those seen at < 8 weeks compared to those seen at > 8 weeks (13.7 % vs. 5.9%). Subchorionic Hematoma Variables % SAB RR(95% CI) Sep.< 1/3 7.7% (22/284) 1.0 (referent) 1/3-1/2 9.2% (17/184) 1.2 (0.7,2.2) > 2/3 18.8% (9/48) 2.4 (1.2,4.7) MA.< 35 years 7.3% (26/ (referent) 35 years 13.8% (22/159) 1.9 (1.1,3.3) GA> 8 weeks 5.9% (17/290) 1.0 (referent) GA 8 weeks 13.7% (31/226) 2.3 (1.3,4.1) Chorionic bump The Chorionic Bump The chorionic bump is an focal echogenic thickening of the wall of the gestational sac. Probably represents a small hematoma that bulges into the gestational sac. It is associated with a guarded prognosis for the early pregnancy (up to 50% pregnancy loss)

6 Molar pregnancy Is this pregnancy intrauterine? Is this pregnancy intrauterine? Is this pregnancy intrauterine?

7 Is this pregnancy intrauterine? Implantation on C-Section Scar C-section Scar Pregnancy Patient refused treatment

8 A week later C-Section Scar Pregnancies treatment protocol Often misdiagnosed as cervical Natural history is severe placenta accretapercreta Retrospective study of 19 patients had methotrexate injected into sac and embryo and also intramuscularly. F/u for days. No complications. Initial rise in HCG and sac size and vascularity. The steady slow decline. Timor-Tritsch Am J Obstet Gynecol 2012;207:44.e1 Outcome of 60 pts with CS scar pregnancy Group A: 38 patients with FH beat. 3 required ut art embolization no hyst. Group B: 12 patients no FH 10 managed expectantly. 2 had ut art embolication one hysterectomy Group C: 10 patients chose to continue 4 live births and and 9/10 hysterectomy (6 in 2 nd tri) Of the 60 pts, 20 had serious complications: 4 had uterine artery embolization; and 11 had hysterectomies. Timor et al. JUM 2015;34:601 Cervical pregnancy

9 Cervical Pregnancy Cervical Pregnancy Rarest of ectopic pregnancies. Most often resulted in loss of uterus Treatment similar to C-section scar pregnancy Fylstra successfully treated 13 1rst tri. cervical pregnancies with suction curettage & balloon tamponade. Fylstra DL. Am J Obstet Gynecol. 2014;210:581.e1-5 After treatment + HCG where is it? Diagnosing an ectopic pregnancy when there is no IUP or only fluid in uterus: Methotrexate handed out too easily Often hcg is not helpful because the levels remain low, and non doubling is suggestive but not diagnostic enough. Discriminatory threshold is controversial. Used to be IU/L. Probably no single number - but to be conservative, use 3000IU/L as guide. F/U scan and hcg in a few days is key.

10 Hematosalpinx Echogenic free fluid (+clot) The # of Yolks Sacs Indicate the # of Amnions Didi Monodi Pt came in for NT scan

11 Dichorionic versus monochorionic twins 2 yolks monodi 1 yolk mono mono More amnions than chorions 10 wks