 Good evening, everyone. Today we'll be discussing the role of ultrasound in evaluation of first semester pregnancies in the acute setting. Myself, Dr. Suksham Jain, second year resident in Department of Radial Diagnosis at Dr. Divya Patil Medical College Hospital and Reserve Centre Pune. And I am doing this oral paper under the guidance of Professor Dr. Parag Patil. The aims and objective of this study in patients presenting for an evaluation of pregnancy in first semester, the trans-veginal ultrasound is a modality of choice. For establishing the presence of endiuterine pregnancy, evaluating viability, gestational age, multiplicity, and detecting any pregnancy-related complications and diagnosing at topic pregnancies. In this article, we'll be discussing the sonographic appearance of the normal uterine gestation and the most common complications in the first semester in the acute setting. The first semester of the pregnancy consists of the first 12 to 13 weeks calculated as beginning on the first date of last menstrual period. During the first semester, trans-veginal ultrasound sonography is the imaging modality of choice for both diagnosis and imaging follow-up. The advantages of ultrasound include widespread availability, relatively low cost and acquisition and acquisition of real-time and high-resolution images. The initial diagnosis of pregnancy is usually made by identifying the presence of serum beta, serum beta-SCG or urine beta-SCG levels. Ultrason is then utilized in first and second termesters to establish gestational age, viability, and eventually evaluating fetal anatomy. In first semester, pelvic ultrasound is employed to establish presence or absence of the inter-uterine gestational stack and to evaluate the viability of the pregnancy. In second term, it can be used to evaluate a topic pregnancy and other pregnancy-listed complications. This was a prospective study done at Dr. Deva Partil Medical College Hospital and Resource Center tertiary care teaching hospital. 50 women who attended the OPD with complaints of bleeding per with INA were taken a detailed history and a complete general and physical examination was done to arrive as a clinical diagnosis. The patient was undergone an ultrasound examination, both the clinical and ultrasound diagnosis were then correlated. Gestational age is initially calculated from the first day of the LMP, ovulation typically occurs mid-cycle at about day 14 of the menstrual cycle, at which point fertilization is most likely to occur. Thus, by the time of the first menstrual period, fertilization and implantation of the fertilizers won't have occurred. During the first three weeks following conception, the developing gestational stack is below the limit of detection by the transvegenic ultrasound. The growth rate of gestational stack is approximately 1.1 mm per day. And the gestational stack first become apparent on TDS at approximately 4.5 to 5 weeks of gestational stack, gestational age appearing as a round and echoic structure located eccentrically within the ecogenic decidual. So these are the various timelines for the developmental milestone. The most importantly in the 4.5 to 5 weeks, the appearance of gestational stack, then the six weeks, cardiac pulsations, 7 to 8 weeks, fetal spine and 8 to 10 weeks, handbrain on found cell flow. Subsequent to the appearance of gestational stack, two concentric ecogenic lines encircling the central ecogenic collection develops. The outer ring is called the decidual peritilis, while the inner ring represent the decidual capillaries and the corium. This is known as the double decidual stack sign, which is the definitive sign of intrauterine pregnancy. Gestational stack size is measured in three dimensions and the mean stack diameter is used to help estimate the early gestational age. York stack appears as a circular thick walled ecogenic structure with an anechoic center within the gestational stack but outside the amniotic membrane. When at 5 to 5.5 weeks, it can sometimes be seen as a two parallel lines rather than a discrete circle. Embryo, the embryo sometimes referred to as a fetal pole early on becomes apparent at six weeks of gestation and is as a relatively feature less ecogenic linear or oval structure adjacent to the York stack initially measuring one to two mm in length. At this point, the mean stack diameter is approximately 10 mm. The crown drum length is measurement between the cranial and caudal ends of the embryo and is the most accurate measure of the gestational age in the first semester. The CRL gradually increases measuring 10 mm at seven weeks and the lack of visible embryo on periods once the mean stack diameter reaches 25 mm is the diagnostic of pregnancy failure. While fetal pole begins as a feature less structure some fetal anatomy structures become visible at the first semester progress as I first told the spine becomes evident at seven to eight weeks and the hind brain becomes evident at eight to 10 weeks. The amniotic membrane becomes visible around seven weeks and the CRL closely corresponds to the amniotic stack diameter between 6.5 and 10 weeks of gestation. After the fetal urine production commences at about 10 weeks there is a disproportionate enlargement in the amniotic stack related to the corion cavity. The corion and amniotic fuse after the first semester 14 to 16 weeks. This is a TVS in a patient with previously confirmed intra uterine pregnancy and vagina bleeding showing an intra uterine pregnancy with the fetal pole marked by an aerobats. A curvilinear ecogenic membrane is noted around the embryo corresponding to the amniotic membrane. The cardiac activity is seen as early as six weeks of gestation when the embryo is 1 to 2 mm inside the current guidelines of the society of radiologists in ultrasound just establish a CRL cutoff of 7 mm above which one should definitely visualize fetal cardiac activity. The absence of a detectable heartbeat once the embryo measures greater than 7 mm is diagnostic of pregnancy failure. Transvaginal ultrasound shows an intra uterine pregnancy with an embryo of crown lump length 1.1 cm corresponding to 7 weeks, 2 days. And in the second image there are no fetal heart rate was identified compatible with intra uterine embryonic fetal device. So the first semester abnormalities, the first semester TVS is usually performed patient presenting with bleeding and perabdominal pain. Once the pregnancy is established by urine or serotonin beta C level, the TVS is done for these patients to evaluate whether pregnancy is intra uterine or extra uterine to know the gestational age to confirm the viability to diagnose any high-definition mall to look for pregnancy associated with IUCDs. And this first semester TVS in this patient's health and prawn management and health detection of an embryonic pregnancy and evaluation of suspected threatened incomplete complete or misdemeanors. So this is a TVS of an irregularly shaped, the empty gestational sag of means and diameter to eight weeks two days without any fetal pole consistent with the diagnosis of an embryonic pregnancy. Once the intra uterine pregnancy is identified the viability and the presence of absence of abnormal feature must be evaluated the timeline for the visualization of gestational sag, yolk sag and embryo are 55.5 and six weeks respectively, and accurate and consistent deviation from the normal chronological appearance of the structure are highly suspicious for pregnancy failure. The society of radiologist has presented specific guidelines for diagnosing pregnancy failure based on certain characteristics namely CRL by which the embryonic heart rate must be identified as 7 mm. The mean sag diameter by which an embryo should be identified is 25 mm. The absence of an embryo and two consecutive ultrasound exams separated by a fixed time interval. In addition, other findings including empty embryo sag sign, a yolk sag greater than 7 mm, and a disproportionately small gestational sag are highly suspicious for pregnancy failure. So this is a transubdominal ultrasound in a 34 year old woman with a positive beta HCG and designer doing demonstrate intra uterine gestation with a mean sag diameter of 23 mm and a yolk sag diameter of 19 mm. No definite fetal pole was identified instead of the amorphous embryonic structure was identified these findings are suspicious for but not diagnostic for pregnancy failure. So, what is diagnostic for pregnancy failure is that absence of fetal cardiac activity with CRL more than 7 mm. Absence of embryo, if the MSD is more than 25 mm 25 mm and absence of embryo two consecutive exams separated by a specific timeline non visualization of embryo with fetal heart rate two weeks after identification of gestational sag without yolk sag non visualization of an embryo with fetal heart rate 11 or more days after identification of gestational sag with yolk sag. Sub-choreonic hematoma is relatively a common finding in the first semester and has been reported to occur in 18 to 22% in intra uterine pregnancies. Transvaginal ultrasound sub-choreonic hematoma appears as a crescent shaped heterogeneous a vascular collection between the gestational sag between and the deciduous cell is large sub-choreonic hematomas are associated with increased risk of pregnancy loss especially if the hematoma is greater than two thirds of the choreonic circumference. So, this is the transvaginal ultrasound in a pregnant woman shows a gestational sag with an embryo and heterogeneous sub-choreonic collection and circling approximately more than 81, 80 degree of the gestational sag. Spontaneous abortion or miscarriage is clinically defined as a loss of pregnancy before 20th week of gestation or the expulsion of fetus weighing less than 500 gram. There are various types first threatened abortion refers to a clinical scenario in which the patient presents with vaginal squatting bleeding and cramping with a close cervical ores. The pregnancy itself may appear normal or may demonstrate abnormal features who are prognostic factors include abnormal morphology, example small or irregular gestational sag, fetal bradycardia or a large sub-choreonic hematoma. An inevitable abortion involves a similar clinical situation with vaginal bleeding and abnormal cramping but with an open cervical ores on previous. The products of conception may be normally or abnormally positioned within the uterus or may protrude in the survey. So this is the transvaginal ultrasound in a 41 year old woman with a known intrauterine pregnancy presenting with abnormal pain and vaginal squatting. Image one shows an intrauterine gestation with an intrauterine gestational sag with an open cervix. So there was no heart rate identified and on follow up ultrasound in the next day the gestational sag was seen in the cervical canal. This is compatible with the diagnosis of inevitable abortion. An incomplete abortion is a term used when the retained products of conception remains within the uterus after the passage of pregnancy. This often appears as a heterogeneous collection of mass within the uterus while it may be a vascular presence of blood flow enables the diagnosis of the retained products. A complete abortion is the cessation of the vaginal bleeding following the passage of pregnancy without retained products of conception. Lastly a missed abortion is a non viable pregnancy with a closed cervix and no clinical symptoms of miscarriage. So this is a transvaginal scan showing bulky uterus with an intrauterine ecogenic mass with multiple cystic spaces within giving a diagnosis of complete vesicular mole. This is a transvaginal ultrasound showing crumpled gestational sag in a lower uterine segment and an open internal os giving a diagnosis of inevitable abortion. So this is a transvaginal gestational sag with fetal pole but with absent fetal cardiac activity giving a diagnosis of missed abortion. So this is a transvaginal ultrasound of two patients with four semester bleeding showing heterogeneous endometrium ecocomplex with vascularity suggestive of retained products of conception or incomplete operation. Transvaginal ultrasound showing a gestational sag with no fetal poles with a subcarionic hematoma. So this is a transvaginal ultrasound of 32 year old female with a UPT positive and seven weeks of eminoria presenting with bleeding per vaginal showing a well defined heterogeneously hyper-equic ring within ring like lesion in the right end nexa. It shows a significant internal peripheral vascularity and the adjacent fallopian tube appears thickened. These are the common sites for the ectopic pregnancies most common being the tubal ectopic. So the results of my study in a total number of 50 cases the most cases were of threatened abortion, missed abortion and an embryonic pregnancy with the highest being the missed abortion 14 cases out of 50. So correlation of the number of cases based on ultrasound and the clinical diagnosis. In my study the clinical diagnosis of threatened abortion was made in 30 patients while the previous confirmed the diagnosis of threatened abortion only in 11 giving the disparity of 19. So in my study the total out of 50 cases that there was disparity in among in 42 cases giving a disparity of 84%. So this is the comparison of clinical and ultrasound diagnostic accuracy. So cases which were difficult to diagnose clinically will diagnose precisely on TBS. So the majority of cases were of missed abortion followed by threatened abortion 10 cases were diagnosed as an embryonic pregnancy and none of these cases could be diagnosed as clinically as blighted. So this holds true with this study available of the four cases of ectopic pregnancy in the study all were correctly diagnosed by ultrasound and were proved to be ectopic and lobotomy. The results of my study correlated well with Roma soffetal and Neelam Bhardwaj et al and Mamanta Shivnapma et al. In a study done by Mamanta Shivnapma et al the total number of disparities between the clinical and ultrasound diagnosis of the causes of bleeding in first trimester was 118 and the percentage of disparity was 71% while in my study total percentage of disparity was 84%. The disparity was more for threatened abortion and an embryonic pregnancy and the secular mall. It was impossible to diagnose an embryonic pregnancy molar pregnancy clinically so transvaginal ultrasound has an advantage over clinical speculation and is a boon for obstetrician. So the conclusion patients who come to achieve complaints of bleeding per vagina in the first trimester in the ops department are at high risk of abnormal pregnancy. They are suspected subjected to various clinical lab examination but still obstetrician cannot come to a final diagnosis. Here the transvaginal ultrasound helps them to come to an accurate diagnosis. It helps in the emergency management and prevents mismanagement of the cases. In my present study the TVS has helped in establishing diagnosis in whom precise clinical diagnosis is difficult. So these are my references and thank you for your patience.