+HCG, now what? Julianna Papez, DO | May 21, 2020
+HCG, now what?Julianna Papez, DO | May 21, 2020
CORE is a network designed to create a diverse medical community, connecting prenatal providers and professionals in Montana and Wyoming. This supportive network of peers and specialists who are committed to reduce preterm birth rates and improve the health and survival of both mom and baby.
• Welcome• This meeting is for education purposes
• The presentation will be recorded and archived for future reference
• https://www.sclhealth.org/core/
• Questions for discussion• Please enter in CHAT for discussion at the end of the
presentation
• CE / CME – complete a short survey
Today’s Speaker
Julianna Papez, DO
Billings OBGYN Associates
Disclosures
I have no actual or potential conflict of interest in
relation to this program / presentation.
Objectives
• Review normal menstrual cycle and pregnancy dating
• Early pregnancy ultrasound findings
• Discuss abnormal pregnancies• Miscarriages
• Missed, incomplete, complete, threatened
• Ectopic pregnancy• Molar pregnancy
• Caring for early pregnancy loss
Case 1
• 21-year-old G1P0 with unknown LMP presents with a positive home pregnancy test and light bleeding and cramping. Past medical history unremarkable except for a history of a prior exploratory laparotomy for a ruptured appendix at age 7. VSS. Exam benign other than a small amount of dark brown blood in the vaginal vault. Ultrasound shows thickened endometrial lining with no adnexal masses. Corpus luteal cyst on right ovary. Quantative HCG is 598 and blood type is O+
• Now what?
Case 2
• 34-year-old G3P2 @ 6w3d by LMP for new ob visit. She is complaining of nausea, vomiting, but no bleeding or cramping. Medical, surgical, ob history unremarkable. VSS. Exam benign Ultrasound shows intrauterine gestational sac, no yolk sac, no embryo.
• Now what?
Normal menstrual cycle
• First day of last menstrual period• Week one of pregnancy
• Dating based on perfect 28 day cycle
• Ovulation
This Photo by Unknown Author is licensed under CC BY-SA
Fertilization• Sperm lifespan
• 5 days
• Egg lifespan• 12-24 hours
Implantation• Day 0 fertilization
• Day 14 of cycle
• 14 days after LMP
• Day 8-9 after ovulation• Implantation
• 22-23 days after LMP
•
This Photo by Unknown Author is licensed under CC BY
Positive pregnancy test
• Urine pregnancy tests can detect at HCG of 6.5mIU/mL• Shortly after implantation• On average tests detect at 20-
50 mIU/mL
• Best time to test• First day of missed period• Day 28-29• HCG is usually 49 mIU/mL in
urine, 239 mIU/mL in blood
This Photo by Unknown Author is licensed under CC BY-SA-NC
Quantitative HCG
• Doubles every 48 hours for the first 12 weeks of pregnancy• Max at 8-10 weeks
• If stays same or decreases• Suspect abnormal pregnancy
• If rises but not doubles• Close surveillanceThis Photo by Unknown Author is licensed under CC BY
+HCG, now what?
• Determining pregnancy location
• Determining viability
Early ultrasound findings
• Discriminatory zone• HCG of 2500-3500
This Photo by Unknown Author is licensed under CC BY-SA-NC
Early fetal development
This Photo by Unknown Author is licensed under CC BY-SA
Ultrasound findings and HCG
• 4.5-5 weeks gestational age
• Expected ultrasound findings• Thickened endometrial lining
• Gestational sac or intrauterine fluid collection
This Photo by Unknown Author is licensed under CC BY-NC-ND
Ultrasound findings
• 5 to 6 weeks• Yolk sac
• Remains until 10 weeks
This Photo by Unknown Author is licensed under CC BY
Ultrasound findings
• 5.5 to 6 weeks• Fetal pole with cardiac
activity
• Crown rump length for dating
This Photo by Unknown Author is licensed under CC BY
Abnormal early findings
• Gestational sac >25 mm without a yolk sac or fetal pole
• Crown rump length >7mm without cardiac activity
This Photo by Unknown Author is
licensed under CC BY-SA-NC
Evaluation of vaginal bleeding in early pregnancy
• Thorough history
• Physical exam
• Ultrasound
Missed Abortion• Fetal pole with no heart
beat• Crown rump length of
>7mm
This Photo by Unknown Author is licensed under CC BY-SA-NC
Incomplete or complete miscarriage
• Retained products of conception• Management
This Photo by Unknown Author is licensed under CC BY-SA-NC
Threatened miscarriage
• Vaginal bleeding in the presence of a closed cervix• Sonographically visualized IUP with fetal cardiac activity
• Management
Subchorionic hemorrhage
• Blood collection underneath the chorion
• Increased risk of miscarriage and preterm delivery
This Photo by Unknown Author is licensed under CC BY-SA
Ectopic pregnancy
• 2% of pregnancies• Tube
• Ovary
• Abdominal
• Cervical
• Interstitial
• Uterine scar
• HeterotopicThis Photo by Unknown Author is licensed under CC BY-SA
Ectopic pregnancy
• Surgery vs medication• Cardiac activity, size of ectopic, contraindication to
methotrexate, ability to f/u, stable clinically
Molar pregnancy
• Complete • No fetal pole, 46XX or 46 XY
(paternal origin), 15-20% risk of neoplasia
• Partial• Fetal pole, 69XXX or 69XYY
or 69 XXY (paternal origin), 1-5% risk of neoplasia
This Photo by Unknown Author is licensed under CC BY-SA-NC
Medical treatment of miscarriage
• Expectant management • Success rate past 8-10 weeks gestational age
• Medications• Misoprostol 600-800 mcgm oral, buccal or vaginal
• Dilation and curettage
Follow-up
• Realistic expectations
• Follow HCG to zero
• Normal menses in 4-6 weeks after miscarriage
• Bleeding should not last beyond one week
• Emotional support
Future Pregnancies
• Optimize maternal health
• Wait one menses before attempting conception
• Slight increased risk of miscarriage for future
• Workup for 2-3 recurrent miscarriages
Case 1
• 21-year-old G1P0 with unknown LMP presents with a positive home pregnancy test and light bleeding and cramping. Past medical history unremarkable except for a history of a prior exploratory laparotomy for a ruptured appendix at age 7. VSS. Exam benign other than a small amount of dark brown blood in the vaginal vault. Ultrasound shows thickened endometrial lining with no adnexal masses. Corpus luteal cyst on right ovary. Quantative HCG is 598 and blood type is O+
• Now what?
Case 2
• 34-year-old G3P2 @ 6w3d by LMP for new ob visit. She is complaining of nausea, vomiting, but no bleeding or cramping. Medical, surgical, ob history unremarkable. VSS. Exam benign Ultrasound shows intrauterine gestational sac, no yolk sac, no embryo.
• Now what?
Questions?