1st trimester USG, Down

syndrome screen, Hormonal

contraception
By Group B
 First trimester USG
Indications

Less than 13 weeks and 6 days of gestation

To confirm

● Presence of intrauterine activity

● Presence of normal cardiac activity

To estimate gestational age

 First Trimester USG
To rule out :

● Suspected ectopic pregnancy

● Multiple gestation
● Suspected hydatiform mole
● Vaginal bleeding
Early pregnancy assessment by ultrasound
1. Gestational sac
- The first sign of pregnancy
- Seen during the fourth week as thick echogenic ring
located eccentrically at the fundus
2. Yolk sac
- seen within the gestational sac at fifth week
- Appears as regular, round echogenic ring around a
sonolucent centre like a halo
- Presence of irregular, calcified sac and if size >6mm
indicates abnormal pregnancy
3. Embryo
● Visualized as a small dot along the
anterior aspect of the yolk sac at the
gestational age of 5.5 weeks
4. Cardiac activity
● Present when the embryo is 5mm and
gestational sac diameter of 20 mm
around 5.5 weeks of pregnancy
 First Trimester USG
Crown Rump Length

● Measured to determine the

gestational age (7-13 weeks)
● From cephalic end to caudal end of
the embryo
 BIPARIETAL DIAMETER
● Measured after 13 weeks
● Its the largest transverse measurement of
the skull
● Measured from an occipitofrontal scan
plane at level of the fetal thalami and
septum pellucidum cavum
Down Syndrome Screening
1.Ultrasound scan
●Nuchal translucency
●Major structural abnormalities
●Soft markers
2. Maternal serum screening
●Pregnancy-associated plasma
protein-A (PAPP-A)
●Beta-human chorionic
gonadotropin (B-hCG)
●Alpha-fetoprotein (AFP)
●Unconjugated estriol (uE3)
●Inhibin A
USG Scan
1.Nuchal Translucency
●Measurement of sonolucency area in posterior fetal neck that can only be obtained from
crown-rump-length of 45-80 mm, (11- 13 weeks + 6 days of gestation)
●Presence of nuchal fold thickness of ≥3.5mm is associated with increased risk of fetal
chromosomal anomalies and refer to fetal specialist
2.Major Structural abnormalities
●Congenital heart defects such as atrioventricular canal defect and GI defect like duodenal atresia
USG Scan
3. Soft marker ( During anomaly scan associated with an increased risk of Down
Syndrome)
● Echogenic cardiac foci
● Short Femur
● Short Humerus
● Sandal Gap
● Echogenic bowel
● Absent nasal bone
USG Scan
● Choroid plexus cyst
● Mild dilatation of renal pelvis
● Increased pulsatility index of ductus venosus
● Increased frontomaxillary nasal angle
● Tricuspid regurgitation

In the presence of two or more soft markers should prompt referral to fetal
medicine specialist.
Maternal serum screening

1.Combined Screening test

● Offered between 11 weeks and 13 weeks 6 days. Combines NT by ultrasound

with serum biochemistry (B-hCG and PAPP-A) in the first trimester.
● Low levels of PAPP-A is associated with trisomy 13,18 & 21
Maternal Serum Screening
Triple Test (15 - 20 weeks) Quadruple Test ( 15 - 20 weeks)
Increased Inhibin A
Decrease AFP & Unconjugated estriol Decreased AFP & Unconjugated estriol

increase B-hCG Increased B-hCG

Risk cut off value 1:200 Risk cut off value 1:250

Sensitivity: 81% Sensitivity: 84%

More accurate than Triple Test

Prenatal Diagnostic Tests
● Chorionic Villus Sampling
● Amniocentesis

Indications:

● Chromosomal or genetic abnormalities

● Metabolic Disorders
● Hemoglobinopathies
Diagnostic Test
1.Chorionic Villus Sampling
●A catheter is passed via cervix (transcervical route) to sample ‘placental tissue’ under USG guidance. If
uterus is palpable, sampling with needle can be performed via transabdominal route
●Sampled cells subjected for cytogenetic analysis and quantitative fluorescent polymerase chain reaction
(QF-PCR) to detect chromosomal abnormalities
●Can be safely performed after 10 weeks of gestation
●Pregnancy loss with CVS higher compared with 2nd trimester amniocentesis
 Diagnostic Test
2. Amniocentesis
●Invasive procedure performed by inserting a fine needle into amniotic cavity and obtaining sample
of amniotic fluid under continuous USG guidance.
●Performed after 15 weeks of gestation. Early amniocentesis (<14 weeks) has higher fetal loss
rate and increased incidence of fetal talipes and respiratory morbidity.
●Fetal cells in amniotic fluid are analysed by fluorescent in-situ hybridisation (FISH), QF-PCR,
culture & karyotype.
●Complications: Fetal injury, Failure to sample
Hormonal Contraception
 Hormonal contraception

Types:
1.Oral (COCP & POP)
2.Injectable Depo Preparations
3.Implants
4.Contraceptive patches
5.Vaginal rings
 Oral (COCP & POP)

COMBINED ORAL CONTRACEPTIVE PILLS (COCP)

-Combined pills contain a combination of estrogen and progestin in varying amounts
and they are available as Monophasic , Biphasic and Triphasic

TYPES OF COCP

-Monophasic : Fixed amount of estrogen and progestin in each pill .

-Example : Norgestrel + Ethinyl estradiol
Levonorgestrel + Ethinyl estradiol
Norethisterone + Ethinyl estradiol
-Biphasic : Dose of estrogen kept constant and dose of progestin is changed once
during menstrual cycle .
- Example : Desogestrel + Ethinyl estradiol

-Triphasic : Dose of estrogen kept constant and dose of progestin is changed twice
during menstrual cycle.
-Example : Levonorgestrel + Ethinyl estradiol .
MOA:

1. Suppression of ovulation

-It causes negative feedback on hypothalamo-pituitary axis → decrease production of

FSH and LH, the mid-cycle LH surge is inhibited, → as a result, ovulation is inhibited

2. Progestogen components make the endometrium thin and unfavourable for

implantation .

3. Progestogen components also thickens the cervical mucus , and make the sperm
penetration difficult
Side effects:

1. Nausea, vomiting
2. Edema
3. Breast tenderness
4. Venous thromboembolism

Contraindication:

1. > 35 years old

2. Smokers
3. Hypertension
4. Breast cancer
5. Acute liver disease
Non contraceptive uses of COCP

1. Regularization of menstrual cycle

2. Reduce dysmenorrhea
3. Treating hirsutism
4. Endometriosis
5. Abnormal uterine bleeding
How to take pill?
-Start the pill on the first day of cycle

-Take the pill same time everyday

-1 pill daily for 21 days

-Followed by 7 pill free days

-If vomiting or diarrhea, use extra contraception from the onset of illness and
continue it for the next 7 days
Missed pills
If 1 pill is missed

• Take the missed pill as soon as possible.

• Continue the rest of the pack as usual.

• No additional contraception is required.

If 2 or more pills are missed

• Take the most recent missed pill as soon as possible.

• Continue the rest of the pack as normal.

• Additional contraceptive cover is required until 7 consecutive pills have been

taken.

If the :

missed pills are in day 1–7: emergency contraception should be considered.

• If the missed pills are in day 8–14: emergency contraception not needed.

• If the missed pills are in day 15–21: omit the pill free interval.
Progestin Only Pills (POP)
-Contains only progesterone, devoid of any oestrogen
-Commonly used progesterones are norethisterone & levonorgestrel

MOA:
1. thickening cervical mucus to prevent sperm penetration
2. progestin inhibits release of FSH & LH → negative feedback inhibition on
hypothalamus (GnRH) and pituitary gland (FSH, LH) → failure of follicle to
develop and rupture → no ovulation occurs
3. Changing the endometrial lining, disfavour implantation to take place
How to take the pill?
1. Must be taken at precisely same time each day to maintain effectiveness
2. If patient forgets to take even 4 hours late, requires different method of
contraception (barrier method)
3. If start day 1 menstruation, no extra contraception required
4. If start after day 5 of menstruation, extra contraception needed for 48 hours

Side effects : acne, weight gain, menstrual irregularities, breast tenderness/

enlargement, hirsutism , amenorrhoea.
(Depo-Provera) / (Depo-Medroxyprogesterone Acetate) DMPA

Dose : 150mg IM injection once in 3 months

MOA :
● High dose of progesterone - inhibits follicular development
- prevents ovulation
● Changes cervical mucus - prevent penetration of sperms
● Inhibit ovarian function - endometrium becomes thin (prevents implantation)
INJECTABLE
Advantages :
-Better compliance
-Safe during lactating
-Can be used in valvular & complicated
congenital heart disease
Contraindications:
-Breast feeding < 6 weeks postpartum
- Comorbid diseases like diabetes and
hypertension
-Current venous thromboembolism
Disadvantages :
-Weight gain (increase appetite)
-Menstrual irregularities
-Abdominal cramps & discomfort
-Amenorrhea
-Fertility may be delayed (10-12 months)
of last injection
- >2 years long use will cause irreversible
loss of bone density but can recover after
discontinuation
 Implants
Inserting of a rod under skin → rod releases hormone progestin into
bloodstream in a low steady dose:
-thicken cervical mucus that prevents sperm from entering
-change the lining of uterus to become thinner

Types:
●Norplant system
-Uses six rods containing levonorgestrel.
●Implanon
-A single rod insertion subdermally in the upper arm
-It is a progestogen containing etonogestrel 68mg
-Not suitable for smoker and women vulnerable to DVT
IMPLANT
Advantages:
●Ideal for women who cannot use estrogen containing contraception.
●Useful for women who find it difficult to take a pill at the same time every day.
●Not affected by other medications.
●Free of problems for 3 years.

Disadvantages:
●May experience bruising, tenderness or swelling.
●Causes irregular periods for first few cycles.
Contraceptive patches
-Applied to the skin
-Release synthetic estrogen & progestin
-Effect of 1 patch lasts a week
-Patches repeated for 3 consecutive weeks
-1 week will be free - menstrual week
-Repeat the 3 patches again at end of 4th week
-Easy,convenient,expensive
-Efficacy & side effects = combined oral contraceptive pill
 Vaginal ring
-Flexible plastic ring - releases low dose of
progestin & estrogen over 3 weeks
-Made up of ethylene-vinyl acetate copolymer
-It's self administrable
-Ring inserted into vagina for 3 weeks, remove for
1 week (menstrual week)
-May fall out:
○during sexual intercourse
○while straining during bowel movement while
removing tampon
Reference
1.Clinical Protocol In Obstetrics & Gynaecology For Malaysian Hospitals
2.Obstetrics By Ten Teachers
3.Obstetrics Today
4.Essentials of Obstetric & Gynecology Hacker & Moore’s