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The demand for ultrasound in early pregnancy has been increasing steadily, and is now a routine investigation for most women within the first trimester of their pregnancy. It is a safe investigation which provides reassurance, charts normal development, and identifies women with abnormal or high risk pregnancies. Transvaginal ultrasound has revolutionized the diagnosis of early pregnancy as it can detect a pregnancy at an earlier stage, whether it is normal and therefore reassuring, or abnormal and require intervention. Ultrasound is also a useful tool to aid decisions regarding management of abnormal pregnancy, such as ectopic pregnancy or miscarriage. This chapter looks at the important role ultrasound plays in the diagnosis and management of abnormal pregnancy.

Background: The objective of this study was to assess the impact of consultant presence, volume of patients seen and weekend opening on the health and cost-related outcomes associated with different Early Pregnancy Assessment Unit (EPAU) configurations.Methods: This was an observational study with a prospective cohort design. Six thousand six hundred six pregnant women (16 years of age and over) attending EPAUs because of suspected early pregnancy complications were recruited from 44 EPAUs across the UK. The main outcome measures were quality of life, costs, and anxiety.Results: Costs, quality of life and anxiety scores were similar across configurations with little evidence to suggest an impact of consultant presence, weekend opening or volume of patients seen. Mean overall costs varied from £92 (95% CI £85 - £98) for a diagnosis of normally developing pregnancy to £1793 (95% CI £1346 - £2240) for a molar pregnancy. EQ-5D-5L score increased from 0.85 (95% CI 0.84-0.86) at baseline to 0.91 (95% CI 0.90-0.92) at 4 weeks for the 573 women who completed questionnaires at both time points, largely due to improvements in the pain/discomfort and anxiety/depression dimensions. 78% of women reported a decrease in their anxiety score immediately following their EPAU appointment.Conclusions: EPAU configuration, as specified in this study, had limited impact on any of the outcomes examined. However, it is clear that care provided in the EPAU has a positive overall effect on women's health and emotional wellbeing, with significant improvements in EQ-5D and anxiety shown following an EPAU visit. [ABSTRACT FROM AUTHOR]

A cesarean scar pregnancy is an iatrogenic consequence of a previous cesarean delivery. The gestational sac implants into a niche created by the incision of the previous cesarean delivery, and this carries a substantial risk for major maternal complications. The aim of this study was to report, analyze, and compare the effectiveness and safety of different treatments options for cesarean scar pregnancies managed in the first trimester through a registry. This study aimed to evaluated the ultrasound findings, disease behavior, and management of first-trimester cesarean scar pregnancies. We created an international registry of cesarean scar pregnancy cases to study the ultrasound findings, disease behavior, and management of cesarean scar pregnancies. The Cesarean Scar Pregnancy Registry collects anonymized ultrasound and clinical data of individual patients with a cesarean scar pregnancy on a secure, digital information platform. Cases were uploaded by 31 participating centers across 19 countries. In this study, we only included live and failing cesarean scar pregnancies (with or without a positive fetal heart beat) that received active treatment (medical or surgical) before 12+6 weeks' gestation to evaluate the effectiveness and safety of the different management options. Patients managed expectantly were not included in this study and will be reported separately. Treatment was classified as successful if it led to a complete resolution of the pregnancy without the need for any additional medical interventions. Between August 29, 2018, and February 28, 2023, we recorded 460 patients with cesarean scar pregnancies (281 live, 179 failing cesarean scar pregnancy) who fulfilled the inclusion criteria and were registered. A total of 270 of 460 (58.7%) patients were managed surgically, 123 of 460 (26.7%) patients underwent medical management, 46 of 460 (10%) patients underwent balloon management, and 21 of 460 (4.6%) patients received other, less frequently used treatment options. Suction evacuation was very effective with a success rate of 202 of 221 (91.5%; 95% confidence interval, 87.8–95.2), whereas systemic methotrexate was least effective with only 38 of 64 (59.4%; 95% confidence interval, 48.4–70.4) patients not requiring additional treatment. Overall, surgical treatment of cesarean scar pregnancies was successful in 236 of 258 (91.5%, 95% confidence interval, 88.4–94.5) patients and complications were observed in 24 of 258 patients (9.3%; 95% confidence interval, 6.6–11.9). A cesarean scar pregnancy can be managed effectively in the first trimester of pregnancy in more than 90% of cases with either suction evacuation, balloon treatment, or surgical excision. The effectiveness of all treatment options decreases with advancing gestational age, and cesarean scar pregnancies should be treated as early as possible after confirmation of the diagnosis. Local medical treatment with potassium chloride or methotrexate is less efficient and has higher rates of complications than the other treatment options. Systemic methotrexate has a substantial risk of failing and a higher complication rate and should not be recommended as first-line treatment. [Display omitted] [ABSTRACT FROM AUTHOR]

Recent data have indicated a relationship between placental oxygen and angiogenic protein levels in the first trimester of normal pregnancies. Our objective was to investigate if maternal serum levels of angiogenic factors Soluble vascular endothelial growth factor (VEGF) receptor 1 (sFlt-1), soluble Endoglin and placental growth factor (PlGF) are altered in women with symptoms of threatened miscarriage (TM) and if they are predictive of a subsequent miscarriage. Blood samples were collected at 6-10 weeks from women presenting with TM (n = 40), from asymptomatic controls (n = 32) and from non- pregnant women in their luteal phase (n = 14). All samples were assayed for serum level of sFLT-1, PlGF, sEndoglin and HSP70 using commercial ELISAs. Samples were analysed retrospectively on the basis of pregnancy outcome. TM group included 21 women with a normal pregnancy outcome and 19 with subsequent complete miscarriage. The latter subgroup had significantly lower mean maternal serum (MS) sFlt-1 (83%, P<0.001) and PlGF (44%, P<0.001) compared to those with a normal pregnancy outcome. Asymptomatic control pregnant women had similar MS levels of sFlt-1 and PlGF compared to the TM patients with a normal outcome. The mean MS sFlt-1 (>10 fold) and MS PlGF (∼2 fold) levels were significantly (P<0.001) higher in control pregnant women compared to the non-pregnant group in the luteal phase of the menstrual cycle. Soluble Endoglin was not altered in the normal pregnant women compared to non pregnant women, although lower in the TM subgroup with a subsequent miscarriage (∼25%, P<0.001) compared to TM with a live birth. There was no significant difference in the mean MS HSP 70 levels between the different groups. This study shows that sFlt1 and PlGF MS levels are increased by several folds in early pregnancy and that MS sFlt-1 and MS PlGF are markedly decreased in threatened miscarriage patients who subsequently have a miscarriage suggesting these proteins are sensitive predictive markers of subsequent pregnancy loss. [ABSTRACT FROM AUTHOR]

Diazepam transfer by the first trimester human placenta was investigated at pregnancy termination between 6 and 12 weeks of gestation. Fetal fluid samples were obtained from the exocoelomic and amniotic cavities of 65 pregnancies between 8 and 25 min following the i.v. administration of 0.1 mg/kg diazepam to the mother. Diazepam was detected in one-third of coelomic fluid samples and two-thirds of amniotic fluid samples. Maternal serum and urine diazepam concentrations correlated negatively and positively respectively, with time from drug injection to sampling. Individual diazepam concentrations were low on the fetal side, and the corresponding concentrations were independent of maternal serum concentrations and the time from drug injection to sampling. Amniotic fluid diazepam content increased significantly with advancing gestational age. A multiple regression analysis showed that the diazepam content of the coelomic fluid was not influenced by maternal serum diazepam concentration, the time from drug injection to sampling or gestational age, whereas only gestational age contributed to the diazepam content of amniotic fluid. These data demonstrate that the placental transfer of diazepam occurs from week 6 of gestation, indicate a preferential transfer of this drug to the amniotic cavity and suggest that diazepam may accumulate in fetal circulation and tissues during organo-genesis. [ABSTRACT FROM PUBLISHER]

The purpose of this study was to investigate the temporal relationship between the early pregnancy peak of circulating human chorionic gonadotrophin (HCG) concentration and the establishment of maternal blood flow in the placental intervillous space. The presence of blood flow echoes within intervillous space was determined by colour Doppler imaging from 44 women with clinically uncomplicated pregnancy between 6 and 18 weeks gestation. Circulating HCG, free α- and βHCG subunits, oestradiol and progesterone concentrations were immunoassayed in blood samples collected at the time of Doppler examination. A continuous intervillous blood flow was detected in all cases with a gestational age ≤11.7 weeks ( = 18) but never before this time. Circulating concentrations of free αHCG, oestradiol and progesterone were linearly or exponentially correlated with gestational age ( = 0.860, 0.903 and 0.538 respectively, all with < 0.001), indicating steady increase of these hormones with advancing gestation. However, the best fitted lines were found to be parabolic for HCG ( = 0.771, < 0.001) and βHCG ( = 0.695, < 0.001), their highest points corresponding to 11.24 and 10.74 weeks gestational age respectively. The close temporal relationship between the Doppler advent of intervillous maternal blood flow and the HCG peak suggests that the establishment of the intervillous blood flow is associated with the decline in circulating HCG concentrations. [ABSTRACT FROM PUBLISHER]

Coelomic fluid and maternal serum samples were collected from 43 normal pregnancies and 18 missed abortions between 7 and 12 weeks of gestation. The samples were analysed for the concentrations of intact human chorionic gonadotrophin (HCG), free αHCG, free βHCG and total protein. The relationships between the biological findings and the ultrasound and pathological features were assessed by regression analysis. In normal pregnancies, intact HCG, free αHCG and free βHCG concentrations were respectively 1.3, 185 and 33 times higher in coelomic fluid than in maternal serum. The coelomic concentrations of intact HCG and free αHCG decreased significantly with advancing gestation. No relationship was found between coelomic fluid and maternal serum concentrations of the different variables. These findings suggest that in normal pregnancies, the concentration of HCG in the coelomic fluid, as in maternal serum, is mainly influenced by cytotrophoblastic differentiation and that the metabolic clearance of HCG molecules is slower in the coelomic cavity than in maternal serum. In missed abortions, the serum concentrations of intact HCG, αHCG and free βHCG and the coelomic concentration of total protein were significantly lower than in normal pregnancies. In three out of nine anembryonic pregnancies diagnosed by ultrasound, embryonic remnants were present at histological examination. The coelomic concentration of total protein was extremely low in all missed abortions with advanced trophoblastic necrosis, whereas the HCG concentration was low when embryonic remnants were absent. These findings support the concept that embryonic and placental development are closely related in the first trimester of human pregnancy, placental biological functions persisting only for a limited period of time after embryonic demise. [ABSTRACT FROM PUBLISHER]

Resistance index (RI) and pulsatility index (PI) in the uterine and spiral arteries, uterine artery peak systolic velocity and intervillous blood flow were recorded by transvaginal colour Doppler imaging in 30 missed abortions and 30 normal pregnancies matched for menstrual age. Pathological examination was performed in both groups within 24 h of Doppler investigation. The mean uterine was significantly (P< 0.01) higher in missed abortions compared to normal controls, whereas the mean uterine RI and peak systolic velocity and spiral RI and PI did not differ. A continuous intervillous flow was found in 16 out of 23 (69.6%) of the complicated pregnancies before 12 weeks of gestation whereas it was not found in controls. In the missed abortion cases, the trophoblastic shell was fragmented or absent in 53% and trophoblastic infiltration and physiological changes in the spiral arteries were reduced or absent in 43 and 63%, respectively. These findings were not related to normal or abnormal Doppler indices. Extended dislocation of the trophoblastic shell and a massive infiltration of the intervillous space and placental bed by maternal blood was also found in cases presenting with a continuous intervillous blood flow before 12 weeks of gestation. These findings suggest that abnormal flow velocity waveforms in early pregnancies complicated by embryonic death are related to deficient placentation and dislocation of the trophoblastic shell that follows embryonic demise. The premature entry of maternal blood into the intervillous space disrupts the materno-embryonic interface and is probably the final mechanism causing abortion. [ABSTRACT FROM PUBLISHER]

To determine whether obstetric outcomes differ between women with endometriosis and those without, where all women undergo first-trimester screening for endometriosis. A prospective observational cohort study. The Early Pregnancy Unit at University College London Hospital, United Kingdom. Women with a live pregnancy progressing beyond 12 weeks' gestation and concurrent endometriosis (n = 110) or no endometriosis (n = 393). All women underwent a pelvic ultrasound examination in early pregnancy to examine for the presence of endometriosis and uterine abnormalities. The primary outcome of interest was preterm birth, defined as delivery before 37 completed weeks' gestation. Secondary outcomes included late miscarriage, antepartum hemorrhage, placental site disorders, gestational diabetes, hypertensive disorders of pregnancy, neonates small for gestational age, mode of delivery, intrapartum sepsis, postpartum hemorrhage, and admission to the neonatal unit. Women with a diagnosis of endometriosis did not have statistically significantly higher odds of preterm delivery (adjusted odds ratio [aOR] 1.85 [95% confidence interval {CI} 0.50–6.90]), but they did have higher odds of postpartum hemorrhage during cesarean section (aOR 3.64 [95% CI 2.07–6.35]) and admission of their newborn infant to the neonatal unit (aOR 3.24 [95% CI 1.08−9.73]). Women with persistent or recurrent deep endometriosis after surgery also had higher odds of placental site disorders (aOR 8.65 [95% CI 1.17–63.71]) and intrapartum sepsis (aOR 3.47 [95% CI 1.02–11.75]). We observed that women with endometriosis do not have higher odds of preterm delivery, irrespective of their disease subtype. However, they do have higher odds of postpartum hemorrhage during the cesarean section and newborn admission to the neonatal unit. [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate the use of biological serum markers, available routinely in most hospital clinical laboratories, in predicting successful outcomes of expectant management in women presenting with a missed miscarriage. This is a single centre observational prospective study over a 16-month period. Among the 490 women who consented to the study protocol, 83 presented with missed miscarriage during the first trimester of pregnancy and opted for expectant management. The mean gestation sac diameter and volume of the gestation sac were recorded during ultrasound examination. Maternal serum samples were obtained in each case and assayed for human chorionic gonadotrophin, progesterone, pregnancy associated plasma protein A (PAPP-A) and high-sensitivity C-reactive protein using commercial assays. When examined individually, maternal age ( P = 0.01), progesterone ( P = 0.03) and PAPP-A ( P = 0.02) were all significantly associated with successful expectant management. Increased maternal age was associated with an increased chance of success with the odds of success increased by around 75% for a 5-year increase in age. Higher values of progesterone and PAPP-A were associated with a reduced chance of successful management. Low maternal serum progesterone concentration was the strongest parameter associated with a successful spontaneous completion of miscarriage. [ABSTRACT FROM AUTHOR]

Maternal serum high-sensitivity C-reactive protein (HSCRP) was evaluated in predicting spontaneous abortion in spontaneous pregnancies presenting with threatened spontaneous abortion. Seventy-one cases of threatened spontaneous abortion (group A) and 71 asymptomatic controls (group B), matched for gestational and maternal age, body mass index and smoking status, were included. Maternal serum samples were evaluated for HCG, progesterone, pregnancy-associated plasma protein-A (PAPP-A) and HSCRP using standard bio-assays. No difference was observed in ultrasound measurements, and median progesterone maternal serum level was significantly lower ( P < 0.05) in group A compared with group B. In group A, the median of all ultrasound and maternal serum parameters was significantly lower ( P < 0.01) compared with group B. The median gestational sac diameter, volume and median HSCRP and PAPP-A levels were significantly increased ( P < 0.05) in group A, with a normal outcome compared with group B, probably owing to the inflammatory reaction associated with intrauterine bleeding. In group A patients destined to abortion, the gestational sac development and corresponding protein synthesis fell before the fetal heart activity stopped; in spontaneous pregnancies, maternal serum HSCRP did not provide additional information for the management of threatened spontaneous abortion but warrants further research in assisted reproduction pregnancies. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To investigate the feasibility and possible value of routine screening for ovarian pathology in asymptomatic pregnant women at 11–14 weeks’ gestation. Study design: A policy of routine ovarian visualization was implemented in 2925 pregnant women attending for a nuchal translucency scan at 11–14 weeks’ gestation. In all cases, an attempt was made to visualize the ovaries on transabdominal ultrasound scan. Simple cysts were defined as unilocular cysts with regular internal walls and no solid components, which contained clear anechoic fluid. All other cysts were classified as complex. Simple cysts <5cm in diameter were all managed expectantly with no further follow-up. All women with large simple cysts ≥5cm in diameter or complex cysts had further detailed follow-up scans. Surgical intervention during pregnancy was offered to women with clinical symptoms suggestive of cyst complications or those with ultrasound features suggestive of malignancy. All other women were managed expectantly until after delivery. Results: Adnexal cysts were found in 728/2925 (24.9%) pregnant women. 400/728 (55%) women had simple cysts <5cm in diameter, whilst 328/728 (45%) women had large simple or complex cysts requiring follow-up. On subsequent scans, cysts resolved spontaneously in 278/328 (84.8%) women. A total of 33/728 (4.5%) women with ultrasound evidence of adnexal cyst underwent surgery. In one woman the intervention was required because of pain, one woman had suspected cancer on ultrasound scan and the remaining 31/33 (94%) of operations were performed at patients’ requests. All the cysts were found to be benign on histological examination. The overall intervention rate was 1.1/100 screened pregnant women or 4.5/100 cysts detected on ultrasound scan. Conclusion: Asymptomatic adnexal cysts detected in the first trimester of pregnancy are unlikely to be malignant or to cause clinical symptoms antenatally. The policy of routine ultrasound visualization of the ovaries in pregnancy cannot be justified. [Copyright &y& Elsevier]