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ULTRASOUND OF FIRST TRIMESTER

ULTRASOUND APPEARANCE OF NORMAL FIRST TRIMESTER PREGNANCY

Till about 3 –5 menstrual weeks the blastocyst is too small to be resolved with U/S. The earliest sign
of pregnancy is prominent endometrial echo.This is nonspecific and unreliable.(present at 4
menstrual weeks). The first reliable evidence of intra-uterine pregnancy is appearance of gestational
sac seen at about 5 menstrual weeks on trans abdominal scan.(3-4 days earlier on trans vaginal
scan.).Sac size is approx. 5-8 mm in diameter when first seen. And grows approx. 1-1.5 mm/day.An
important feature which distinguishes intrauterine pregnancy from other intra-uterine fluid
collections is DOUBLE DECIDUAL SAC (DDS).Two concentric echogenic lines seen surrounding
a portion of gestational sac.The inner representing the decidua capsularis and outer representing d.
parietalis with thin uterine cavity appearing as a anechoic (blackish) layer in between.

Figure shows development of deciduae in early pregnancy.Between Decidua parietalis and

D.capsularis lies the uterine cavity.This space is the reason we are able to see Double decidal
gestational sac.

Double ring appearance(White arrows ) Yolk sac(Y)—first structure seen within

first sign that pregnancy is truly the gestation sac.(6)wks
intra-uterine.

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Secondary yolk sac is the earliest structure seen (at 6 wks) within the gestational sac .Embryo is
usually seen at 61/2 –7 weeks when it is 5-10 mm in length.Cardiac motion is

Embryo(E) at 61/2 wks.Y-Yolk sac TAS showing amnion(Arrowed)

surrounding 7 wks embryo

normally seen as soon as the embryo appears.However rarely a small normal embryo
(Less than 10mm).may be seen in which cardiac motion is not visualized in initial scan.
Placental reaction can be seen at about 8-9 weeks.Umblical cord is usually seen at 8-9 weeks
at which time the fetal head and ventricles can also be seen.Amnion is seen as a thin
membrane separating embryo from secondary yolk sac as early as 6 weeks .It is usually
obliterated at 16 weeks ,however at times it may persist till end.Fetal spine and limb buds
can be seen at 8-9 weeks.Long bones at 10-11 weeks.Bladder and stomach are usually seen at
about 13-15 weeks while fetal kidneys are visualized from 14-20 weeks.

8-9 wks pregnancy showing developing head. (rhombencephelon) as cystic structure(Arrow)

ULTRASOUND OF FIRST TRIMESTER COMPLICATIONS.

SPONTANEOUS ABORTION
Spontaneous abortion is the natural termination of an Intra uterine Pregnancy prior to 20
weeks. It is common and occurs in about 10%-20% of observed pregnancies. Occult
abortions occur even more frequently, since it is estimated that up to 50% of conceptions
terminate prior to implantation. Clinically apparent spontaneous abortions occur after

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implantation, but usually before 12 gestational weeks. The majority of these early abortuses
have chromosomal anomalies. Other risk factors include a coexisting intrauterine
contraceptive device, smoking, ingestion of toxins and drugs, pelvic irradiation, and some
medical diseases, including diabetes mellitus and TORCH infections..

A complete spontaneous abortion appears on U/S as an empty uterus with a normal central
cavity echo.Uterus may be mildly enlarged.

An incomplete abortion may have similar appearance if the retained tissue is scant.If
sufficient gestational tissue is present, increased or irregular echoes will be present within the
central uterine cavity.

THREATENED ABORTION

The term threatened abortion applies to women during the first 20 weeks of pregnancy and
who have vaginal bleeding and who on the basis of clinical evaluation are considered to have
potentially viable gestation. Most women with threatened abortion having live embryo do not
show an apparent cause however at times there is U/S evidence of abruption.

A missed abortion is diagnosed when embryo is identified but cardiac activity is absent.

POINTS SUGGESTING ABNORMAL SAC

1.Menstrual age not corresponding to ultrasound assessed gestational age.

2.Thin walls of gestational sac with weak echogenicity.

3.Pointed end.

4.Gestational sac size is greater than 30mm on transabdominal scan and greater than 22 mm
on transvaginal scan and sac is still empty.Extra-caution has to be applied in such cases since
pts. on proluton(progesterone) have been found to have relatively larger normal sac but
without the presence of fetal node .
Such pt. on many occasions have been diagnosed as blighted ovum but follow-up scan
showed appearance of fetal node.It is thus suggested that when the sac margins are relatively
thick and regular and h/o bleeding is absent,a repeat scan after 7- 10 days should be
done(whenever possible) even if the sac size is big without the presence of fetal node.

5.Sac lying in the lower uterine segment.

6.Yolk sac relatively large with respect to the sac size.

7.Sac—embryo size disparity.i.e.Sac size is relatively large compared to the size of the
embryo.

8.Absent foetal cardiac pulsations.

9.Foetus -fixed &dependent.

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Abnormal gestational sac with Pointed ends(TVS)

weak surrounding echogenicity

Irregular sac margins

Abnormal Hourglass shaped empty sac Sac lying in cervix.Os open

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Abnormal aborting sac. Os open.(inevitable abortion)

Abnormal large yolk sac.(6.8mm) no embryo seen Embryo-sac size disparity

Thick irregular endometrial echo-retained products(Incomplete abortion)

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Intradecidual bleed seen as hypo-echoic area close to sac Retrochorionic bleed(b)

TROPHOBLASTIC DISEASE

Persistence and subsequent proliferation of chorionic villi from blighted ovum.Frequent

presenting signs are enlarged uterus with bleedingP/V with symptoms of pregnancy.The
typical vesicular appearance on U/S may not be present in first trimester molar pregnancies
and appearance may mimic that of missed abortion.A molar pregnancy however will have
high HCG levels relative to sac size while missed abortion will be associated with normal to
low HCG levels.

Molar Pregnancy(m) Snow storm appearance-typically

seen in molar pregnancy

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