EMBRYONIC DEMISE

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Embryonic Demise

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The embryonic phase of development is complete by the end of the 10th G.wk embryonic phase

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in the presence of clear-cut sonographic evidence that a nonliving embryo is present, the term embryonic demise should apply Only about 1/2 of zygotes persist as a clinical pregnancy.

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True gestational sacs implant into the endometrial lining, and are seen eccentric to the endometrial canal. Fluid collections within the canal are not true gestational sacs.

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The G.S and yolk sac are seen beginning at 4.5-5 weeks, before a recognizable embryo is seen

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Small amounts of bleeding into the cavity are commonly seen, and may surround much of the gestational sac, but if the decidua basalis remains intact, the gestation can and usually does continue to develop normally.

Clinical Details : 

Clinical Details

first trimester : 

first trimester 50% fail mild vaginal bleeding and/or cramping 50%continue 25%

gestational sac : 

gestational sac

gestational sac : 

gestational sac The earliest visible gestational sac is seen at 4.5 weeks as an echogenic ring, with a tiny central hypoechoic area. Gestational. Age = 30 + Mean Sac Diam.(mm.)

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intradecidual sac sign

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This very small sac is positioned within the anterior endometrium. Note the linear central cavity echo positioned just deep to the sac. This relationship characterizes a normal-appearing intradecidual sac sign. intradecidual sac sign

double decidual sac : 

double decidual sac

double decidual sac : 

To confidently diagnose an IUP, most sonographers rely on the double decidual sac (DDS) finding, which is not universally present until the MSD is 10 mm (40 days GA) . double decidual sac

cardiac activity : 

cardiac activity

cardiac activity : 

when using a transabdominal approach, cardiac activity should be visible by 8 weeks GA., 9 mm should be considered the discriminatory embryonic length for detecting cardiac motion with a transvaginal approach. can detect cardiac activity approximately by 6 weeks GA. 5mm be considered the discriminatory embryonic length for detecting cardiac motion cardiac activity

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YOLK SAC

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The yolk sac is attached to the embryo by the body stalk and flouts freely in the extraemryonal coelom, until 10th week.

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Yolk sac is the first structure to be seen at T.V.S. even before fetal pole is seen.

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Using a vaginal approach, the yolk sac should be observed by 5.5 WK GA. yolk sac yolk sac

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In measuring yolk sac inner to inner diameter is to be measured. The walls of yolk sac are not to be included in the measurement. A yolk sac diameter more than 5.5 mm between 5 to 10 weeks of menstrual age, is associated with poor outcome. A gestational sac with a mean diameter of more than 8 mm without a yolk sac, indicate non-viability.

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Yolk Sac Seen at G.S. diameter. By T.V.S. 5 weeks preg. 8 to 10 m.m. By T.A.S. 6 weeks preg. 20 mm At transvaginal sonography, yolk sac is seen one week earlier than trans abdominal sonography. YOLK SAC

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Yolk sac should be seen when sac is 8mm. MSD by vaginal probe( 8+30=38d), or 20 mm(20+30=50d). MSD by abdominal probe. yolk sac

NORMAL YOLK SAC : 

NORMAL YOLK SAC TAUS (MSD) is 20 mm 7 weeks TVUS MSD is 8 mm 5.5 weeks Yolk sac must be visible

Size of Yolk sac : 

Weeks of gestation Yolk sac diameter 5 weeks 3 to 6 mm 6 weeks 4 to 5 mm 7 weeks 5 mm. (Embryo seen) 8 weeks 5 mm. (embryo 10mm) After 7 weeks yolk sac is static, till it disappear by the end of first trimester. Normal acceptable size of yolk sac 5.0 .to 5.5mm Size of Yolk sac

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If a small saclike structure is imaged but it does not contain a yolk sac, it is often not possible to determine if the intrauterine finding is the result of an early IUP or a pseudo sac associated with an ectopic pregnancy. In these instances, careful evaluation of the adnexa may be helpful to detect an ectopic pregnancy. Occasionally, serial ultrasound and/or hCG determinations may be required to determine the etiology for the intrauterine sac If no yolk sac

Visualizing a dead embryo : 

Visualizing a dead embryo

Visualizing a dead embryo : 

Visualizing a dead embryo using a transabdominal approach, 9 mm should be considered the discriminatory embryonic length for detecting cardiac motion. Used in this manner, when a transvaginal approach was used, 5 mm be considered the discriminatory embryonic length for detecting cardiac motion.

TVUS : 

TVUS TAUS CRL>5MM FETAL DEMISE NO CARDIAC MOTION CRL>9MM NO CARDIAC MOTION

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Predicting a poor outcome

Predicting a poor outcome : 

Predicting a poor outcome mean embryonic heart rate (MEHR) mean gestational sac size (MSS) Abnormal yolk sac/amnion Subchorionic hemorrhage Abnormal sac criteria Doppler findings

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the MEHR is 101 beats bpm/ 5-6 weeks GA This rate increases to 143 bpm / 8-9 weeks GA 1-mean embryonic heart rate

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it is not unusual for an initially detected embryonic heart rate to be somewhat slower than the fetal heart rate recorded later in pregnancy. In one study, all embryos from 5+ to 8+ weeks GA in which the heart rate was less than 85 bpm resulted in spontaneous miscarriage (Benson, 1994) 1-mean embryonic heart rate

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At 5.5 weeks gestational age, the embryonic heart rate was 92 beats per minute. Follow-up scan revealed embryonic demise

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Small sac size: From 5.5-9 weeks GA, the mean gestational sac size (MSS) is normally at least 5 mm greater than the CRL (MSS) 2-Mean sac size

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When this difference is less than 5 mm, the subsequent spontaneous abortion rate exceeds 90% (Bromley, 1991) (MSS) 2-Mean sac size

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This embryo was 8 weeks gestational age. Lack of fluid surrounding the embryo results in a disproportionately small sac. A follow-up scan 1 week later revealed demise (MSS)

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3-Subchorionic hemorrhage

Early pregnancy bleeding : 

Early pregnancy bleeding Subchorionic hemorrhage 18%

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Several authorities have suggested that the size of the blood clot can be used to predict the outcome (Abu-Yousef 1987); this has not been universally accepted (Dickey, 1992). 3-Subchorionic hemorrhage

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A large Subchorionic hemorrhage is present superior to the gestational sac (white arrow). Follow-up scan revealed embryonic demise

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Hemorrhage volume (Estimated from formula Length (cm) X Height (cm) X Depth (cm) X 0.52 = Volume ml), less then 75-200 ml. is often associated with continued development 3-Subchorionic hemorrhage

4-Abnormal yolk sac/amnion : 

4-Abnormal yolk sac/amnion

NORMAL YOLK SAC : 

NORMAL YOLK SAC TAUS (MSD) is 20 mm GA of 7 weeks TVUS MSD is 8 mm GA of 5.5 weeks Yolk sac must be visible

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An enlarged yolk sac, greater than 6 mm in diameter can be the first sign of an eventful pregnancy failure. Yolk sac that is Too small, Solid, Too large Fragmented, or Irregular, is associated with poor pregnancy out come.

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Fetal pole Yolk sac at L.M.P. 2 months Yolk sac 6.2 mm. A poor prognosis was forcasted to the patient.

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Both cases has poor prognosis. Big yolk sac measuring 6.5mm ll Big yolk sac measuring 6.2mm

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Poor prognosis in both the cases Large yolk Fractured yolk sac Abnormally large yolk sac results from accumulation of nutrients, not used by the embryo.

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Big yolk sac and no fetal pole. A case of blighted ovum Gestational sac is irregular. Measures 18mm. No fetal pole or yolk sac seen Confirms as missed abortion

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L.M.P. 1 month 25 days. Yolk sac is seen shown by arrow. In the fetal pole in head, shows a collection of fluid -called Rhombencephalon. It mimics a second yolk sac. Be careful not to describe it as second yolk sac. Yolk sac Rhobencephalon (not to be mistaken As second Yolk sac)

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A limitation of the transvaginal approach is if a large pelvic mass is present. Most often, large or strategically placed calcified uterine fibroids cause this problem. Under these circumstances, an abdominal approach should be used in an effort to image the uterus and its contents.

A normal appearing yolk sac is seen on this transvaginal scan done at 5.5 weeks gestational age. : 

Yolk sac 3mm A normal appearing yolk sac is seen on this transvaginal scan done at 5.5 weeks gestational age.

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An abnormally large yolk sac is present (arrow) within this gestational sac. Diameter measured 10 mm. Follow-up imaging confirmed a failed pregnancy.

5-Doppler findings : 

5-Doppler findings

5-Doppler findings : 

5-Doppler findings conflicting reports exist with regard to the usefulness of first trimester Doppler for predicting pregnancy outcome. Some reports suggest if the resistive index is measured at the Subchorionic level and exceeds 55, a high likelihood of spontaneous abortion exists (Jaffe, 1995); however, others claim that Doppler analysis of these vessels are not predictive of outcome (Frates 1996).

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6-Abnormal sac criteria

DDS : 

DDS MSD is 5 mm TvUS yolk sac TvUS MSD 8mm embryo TvUS MSD 20mm transvaginal

DDS : 

DDS MSD is 10 mm TAUS yolk sac TAUS MSD 20mm embryo TAUS MSD 25mm transabdominal

Visualizing an "empty" gestational sac : 

Visualizing an "empty" gestational sac An "empty " gestational sac is the result of 1 of 3 entities: 1) a normal early IUP, 2) an abnormal IUP, or 3) a pseudo gestational sac in a patient with an ectopic pregnancy.

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Using a vaginal approach, the mean diameter of this sac exceeded 20 mm. Neither a yolk sac nor embryo was visible. These findings are consistent with a "blighted ovum

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Note the irregular shape to this sac. In addition, the choriodecidual reaction is somewhat thin. Not surprisingly, this pregnancy failed.

Growth rate : 

Growth rate In normal gestation, mean sac growth is 1.13 mm/day.

Choriodecidual appearance : 

Choriodecidual appearance This refers to the sonographic appearance of the echoes that surround an early intrauterine gestational sac. An abnormal appearance includes a distorted sac shape. a thin (<2 mm), weakly echogenic, irregular choriodecidual reaction; absence of the double decidual sac sign when the MSD exceeds 10 mm

The Living Embryo and threatened abortion : 

The Living Embryo and threatened abortion

The Living Embryo and threatened abortion : 

The Living Embryo and threatened abortion The presence of an embryonic heartbeat is highly reassuring. When visualized by Low Resolution Abdominal sonography, more than 90% of pregnancies continue Visualization by high resolution vaginal sonography is associated with a 70% continuance rate.

The Living Embryo and threatened abortion : 

< 6 week., 33% are lost With bleeding 16% are lost if no bleeding present The Living Embryo and threatened abortion

The Living Embryo and threatened abortion : 

7-9 week 10% are lost With bleeding 5 % are lost if no bleeding present The Living Embryo and threatened abortion

The Living Embryo and threatened abortion : 

9-11 week 4 % are lost With bleeding 2% are lost if no bleeding present The Living Embryo and threatened abortion

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The prognosis for the living embryo improves as gestation proceeds

Visualizing a central cavity complex : 

Visualizing a central cavity complex

Visualizing a central cavity complex : 

Visualizing a central cavity complex When the central cavity complex is abnormally thickened (and often irregularly echogenic), the differential diagnosis includes: intrauterine blood, retained products following an spontaneous abortion. decidual changes secondary to an early but not yet visible intrauterine pregnancy. or a decidual reaction from an ectopic pregnancy.

Degree of Confidence : 

Degree of Confidence If certain findings are not observed at the appropriate time, The embryo always should be given the benefit of the doubt, and a follow-up ultrasound examination should be performed .

False Positives/Negatives : 

False Positives/Negatives Prior to visualizing the yolk sac, it is often not possible to be certain if a small intrauterine saclike structure is due to an early intrauterine pregnancy (normal or abnormal), or a pseudosac associated with an ectopic pregnancy. This is because it may not be possible to clearly identify the DSS. Under these circumstances, a follow-up examination should be performed if clinically feasible.

False Positives/Negatives : 

Occasionally, a subchorionic hemorrhage may resemble a second intrauterine sac. However, since most of these women are bleeding, with careful scanning, the correct diagnosis usually can be made. Whenever uncertainty exists, perform a short interval follow-up examination at 5-7 days False Positives/Negatives