normal early pregnancy imaging
TRANSCRIPT
1st trimester : the period from fertilization of
the ovum to the start of the 13th post
menstrual week.
Imaging approaches
1- Transvaginal ultrasound : is the main
stay of early pregnancy as it offers
excellent resolution for developmental
stages.
2- Transabdominal ultrasound : excellent for
rapid confirmation of a live IUP
3- Doppler : the use of Doppler should be avoided in 1st
trimester due to concerns regarding heating effect and
embryonic damage and some recent studies correlating
the abuse of Doppler in 1st trimester and autism. The
usual Doppler sign is the “ring of fire” which is a non
specific finding as it can be found in ectopic pregnancy
and in the corpus luteum as well as normal chorionic
tissue
4- M-Mode : is used to document
cardiac activity in the embryo
5- MRI : current recommendations are to
avoid MRI studies as the its effect on embryo
at such early stage is not sufficiently studied
6- CT : as an ionizing radiation it’s
contraindicated in 1st trimester except in
grave indications as in trauma
7- 3D/4D scanning
Embryologic stages
1- Embryo formation :
-Ovum + sperm = zygote
-Cleavage of zygote = morula
-Central fluid filling of the morula= blastocystic cavity that separates trophoblast from inner cell mass and is divided into
- trophoblast : embryonic part of the placenta
- Inner cell mass ( embryoblast) : Primordium of embryo
- Embryoblast forms a bilaminar embryonic disc
- The embryonic disc transforms into a 3D C-shaped embryo be the beginning of 6 week post menstrual
Timing of some embryonic
events
Neural tube closes by day 26 (5th-6th
weeks)
Heart is partitioned by the end of 8th week
but cardiac activity can be detected prior to
that when the embryo reaches a length of 5-
6 mm
Limb-buds are seen by 9-10 weeks
Embryo gives the recognizable human form
by the end of 10 weeks
Physiologic Bowel herniation : because the bowel
grows rapidly than the rest of the embryo it
herniates at the base of the cord then it
undergoes rotation within the cord then returns to
abdominal cavity . Please Note that the liver never
herniates normally.
Multiple Pregnancy
Multiple pregnancies and types of twinning depends on the number of zygotes and timing of division and they are :
1- Dizygotic twins : two fertilized ova and they are all dichorionic , diamniotic
2- Monozygotic twins : the amnionicity and chorionicitydepends by the time of zygote division
- Before 3rd day post conception : diamniotic, dichorionic
- 4th-8th day post conception : monochorionic , diamniotic
- Cleavage of the inner cell mass of blastocyst after 8th day post conception : monochorionic, monoamniotic.
- Incomplete cleavage of embryonic disc after 13th day post conception : conjoined twins
Monoamniotic monochorionic
twins
Monochorionic Diamniotic
Twins
Diamniotic Dichorionic twins
Multiple Pregnancy
Normal imaging milestones
1- Double decidual sac Sign (DDSS) : is the earliest sign of IUP seen by 4-5 wks from LMP by TV U/S formed of two echogenic rings and it’s where the fertilized ovum implants itself into the decidualizedendometrium and formed of :
- Decidua Parietalis : outer ring lining uterine cavity
- Decidua capsularis : Inner ring covering the free margin of the G.S
- Decidua Basalis : which the endometial base of the sac
Decidua basalis + chorion frondosum = placenta
Yolk sac
The presence of the yolk sac within the uterus confirms IUP
Seen by 5-6 weeks from LMP
Round and echogenic
Though the amnion develops embryologically before the yolk sac the yolk sac is easier to identify by U/S
An imaging hint: the number of the yolk sacs is equal to the number of amnions so in multiple pregnancies count the yolk sacs to determine amnionicity.
The Embryo
First seen as a focal thickening in the yolk sac
“ Diamond ring Sign”: Embryo appears as the echogenic (diamond) on top if the yolk sac (ring)
“ Double Bleb “ sign : yolk sac and amniotic sac and the embryo is in the amniotic sac
Distinct embryo with cardiac activity is seen by 5-6 weeks after LMP and a CRL of 5 mm is the discriminatory value of the presence of cardiac activity known as the “ 5 Alive “ rule.
Diamond ring Sign
Double Bleb Sign
Gestational sac
Mean sac diameter :
- > 10mm you must see a yolk sac
- > 18-20mm must see and embryo
Failing Pregnancy
Failure of any of the above milestones
means a failed pregnancy
Some Imaging Protocols
When your measuring the Mean Sac
Diameter (MSD) : measure only the
sonolucent area and don’t include the
echogenic chorionic rim, also measure the
sac in three different diameters and take
their average .
Crown – Rump length: is the most accurate
means of dating pregnancy that should be
used once an embryo is visible , remember
not to include the yolk sac in your
measurement and only measure the longest
axis of the embryo
Normal 1st trimesteric
Measurement MSD increases by about 1mm per day
Sac Diameter should be about 1 cm longer than CRL
Cord length at this stage is almost as the embryonic length
Embryonic heart rate :
-< 6week = 110-115 bpm
- By 8 weeks = 144-159 bpm
- >9 weeks = 137-144 bpm
- A rate <90 bpm is considered embryonic bradycardia
Anomalies that could be
detected in 1st trimester
Anencephaly, acrania,
holoprosencephaly (don’t mistake
normal rhombencephalon for a cystic
brain mass)
“Mickey Mouse Appearance “
“ Bart Simpson” Appearence
Normal Rhombencephalon
Cystic hygroma
Abdominal wall defects but beware not to
mistake them with physiologic hernia
1st trimester screening for
aneuploidy
Nuchal translucency : Should be strictly
< 3mm by standardized measuring
techniques
Ductus venosus : there should a continuous
forward flow all through the cardiac cycle in a
triphasic wave form
Nasal bone should be identified as a
separate bone from the skin
Questions you should be able
to answer by the end of your
scan Is there an IUP?
Is there a definite ectopic pregnancy or
suspicious sign of it?
How many gestations are there?
If there are multiple sacs what is the
chorionicty and amnionicity?
Is there a yolk sac?
Is there an embryo?
Clinical implications
Human chorionic gondatropin (hCG) :
Nomral pregnancy leads to increase in
levels of hCG
Discriminatory level of hCG can be very
useful in the triage of pain and bleeding
in early pregnancy .
If hCG level is > 2000 expect to see IUP
Triage decision tree :
1- Empty uterus with hCG > 2000 D.D includes
ectopic pregnancy and complete miscarriage , if
there are clinical signs of ectopic pregnancy you
have to choose between methotrexate injection
v.s surgery but if the patient is stable with no
U/S features of ectopic pregnancy follow up with
serial hCG titring and U/S
2- Empty uterus with hCG <2000 your differential
diagnosis includes ectopic pregnancy ,
miscarriage and normal early pregnancy