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+HCG, now what? Julianna Papez, DO | May 21, 2020
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+HCG, now what?

Dec 11, 2021

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Page 1: +HCG, now what?

+HCG, now what?Julianna Papez, DO | May 21, 2020

Page 2: +HCG, now what?

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.

Page 3: +HCG, now what?

• 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

Page 4: +HCG, now what?

Today’s Speaker

Julianna Papez, DO

Billings OBGYN Associates

Page 5: +HCG, now what?

Disclosures

I have no actual or potential conflict of interest in

relation to this program / presentation.

Page 6: +HCG, now what?

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

Page 7: +HCG, now what?

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?

Page 8: +HCG, 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?

Page 9: +HCG, 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

Page 10: +HCG, now what?

Fertilization• Sperm lifespan

• 5 days

• Egg lifespan• 12-24 hours

Page 11: +HCG, now what?

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

Page 12: +HCG, now what?

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

Page 13: +HCG, now what?

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

Page 14: +HCG, now what?

+HCG, now what?

• Determining pregnancy location

• Determining viability

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Early ultrasound findings

• Discriminatory zone• HCG of 2500-3500

This Photo by Unknown Author is licensed under CC BY-SA-NC

Page 16: +HCG, now what?

Early fetal development

This Photo by Unknown Author is licensed under CC BY-SA

Page 17: +HCG, now what?

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

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Ultrasound findings

• 5 to 6 weeks• Yolk sac

• Remains until 10 weeks

This Photo by Unknown Author is licensed under CC BY

Page 19: +HCG, now what?

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

Page 20: +HCG, now what?

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

Page 21: +HCG, now what?

Evaluation of vaginal bleeding in early pregnancy

• Thorough history

• Physical exam

• Ultrasound

Page 22: +HCG, now what?

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

Page 23: +HCG, now what?

Incomplete or complete miscarriage

• Retained products of conception• Management

This Photo by Unknown Author is licensed under CC BY-SA-NC

Page 24: +HCG, now what?

Threatened miscarriage

• Vaginal bleeding in the presence of a closed cervix• Sonographically visualized IUP with fetal cardiac activity

• Management

Page 25: +HCG, now what?

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

Page 26: +HCG, now what?

Ectopic pregnancy

• 2% of pregnancies• Tube

• Ovary

• Abdominal

• Cervical

• Interstitial

• Uterine scar

• HeterotopicThis Photo by Unknown Author is licensed under CC BY-SA

Page 27: +HCG, now what?

Ectopic pregnancy

• Surgery vs medication• Cardiac activity, size of ectopic, contraindication to

methotrexate, ability to f/u, stable clinically

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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

Page 29: +HCG, now what?

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

Page 30: +HCG, now what?

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

Page 31: +HCG, now what?

Future Pregnancies

• Optimize maternal health

• Wait one menses before attempting conception

• Slight increased risk of miscarriage for future

• Workup for 2-3 recurrent miscarriages

Page 32: +HCG, now what?

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?

Page 33: +HCG, 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?

Page 34: +HCG, now what?

Questions?