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2nd and 3rd Trimester OB Protocol

Protocol
Protocol will vary with patient age and fetal position
The goal of the exam is to image each structure in the protocol
The protocol is divided up into sections
It is highly recommended that you complete each image in the applicable section
before moving to the next section when possible.

HMP:\Protocols\OBGYN Protocols\2nd Trimester Protocol.docx

Fetal Measurements
nd
2
and 3rd Trimester OB Protocol
Structure/
Scan
Label
Placenta Comp
Heart and
Rate,
Uterine
Cervix, Ovaries,
Adnexa,
Fetal Head
Face
Structures
Order
PlaneImagesLandmarks
Identified
Placenta,
and Fluid
Trans
BPD
Cavum
septum pellucidum, IHF, Thalami
Organ/
Scan
Label
Landmarks
Identified
Axial
and Parietal
bones
Structur
Scan
Label
Landmarks
Identified
Fetal
Order
Plane
Measurement technique
e/
Plane
CHP
Measureme Fetal
IHFPlace calipers on the outside of the
Order
nts
Head
closetPlexus
parietal
bone ventricle
to the inside of the
Choroid
within
Begin
at
move
out of
o farthest
Trycervix,
to get
both superiorly
in one image,
if uterine
not do
parietal
bone
Fetal
Coronal
fundus
HC
Cavum
septum(in
pellucidum,
IHF, Thalami
Head
separately
axial plane)
NO IMAGEo Identify the fetus within the uterus
and Parietal bones
TX
SCAN
o Identify number of fetuses
Fetal
VENTRICLES
IHF
Measurement technique
o Identify fetal lie
THROUGH
o Place calipers outside to outside of the
Head
(indicate
Ventricles
o Determine the right and left sides of the
parietal bones
Transaxia
RT & LT)
fetus
Uterus/
o
Open the calipers with an ellipse that
TXl
HEART RATE Fetal heart and chest
Fetus
surrounds the fetal skull
o IHF
Enlarge image of heart and document
CEREBELLU

IHF,
Cerebral Peduncles, Cerebellum,
VENTRICLES Ventricle
heart rate with M-mode or Spectral
M
Cisterna Magna,
and Nuchal Fold
(indicate
Measurement
Technique
Doppler

Measurement
technique
o Posterior ventricle
RT RATE
& LT) Fetal
TX
HEART
heart and chest
o Place
calipers
on the outsidetoofmedial
the
Measure
internally
o Enlarge
image
of heart lateral
and document
lateral
wall to the outside of the
at glomus
heart
rate with a cine-loop
opposite lateral wall
Uterine
Sagitt
CERVIX ML
Vaginal Canal
CISTERNA

IHF,
Fetal
Face
FACE
OrbitsCerebral Peduncles, Cerebellum,
Cervix
al
Cervix
MAGNA
Cisterna Magna, and Nuchal Fold
Face
Coronal
Mandible
Amniotic Sac
Measurement technique
Sagitt
CERVIX ML
Vaginal
Canalcalipers at the level of the mid
o Place
LENS
Orbits
al
Cervix posterior wall of the cerebellum to the
Echogenic lens (can be in transaxial
Amniotic
Sac of occipital bone
inside
plane)

Measure
Cervical
Length
NUCHAL
IHF, Cerebral Peduncles,
Cerebellum,
o
External
os
to
internal os
FOLD
Cisterna Magna, and Nuchal Fold
NOSE AND
Nostrils
Sagitt
FETAL LIE
Document
presenting
fetal structure

Measurement
technique
LIPS
Upper
lip
al
Cervix
o Place calipers at the level of the mid
o Indicate Breech or Vertex in annotation
posterior
wallextended
of the cerebellum
Face
PROFILE
Forehead,
nose,
chin andfrom
neck
Sagitt ADNEXA SAG RT Adnexa include ovary if possible
the outside of occiptal bone to outside
Midline
al
RT
skin line
Adnexa
Sagittal
Sagitt ADNEXA SAG LT Adnexa include ovary if possible
Abdom
AC
Umbilical vein/portal vein junction
al
LT
en TX
3 points of the spine
Sagitt
PLACENTA
Placenta closest to Cervix
Symmetrical ribs
al
SAG INF
Retroplacental complex
Measurement technique
Sagitt
PLACENTA
Placenta Mid- include cord insertion
o Place calipers on outside of skin line
Placenta
al
SAG MID
Retroplacental complex
directly behind spine and in front of
Sagitt
PLACENTA
Placenta- superior portion
abdomen.
al
SAG SUP
Retroplacental
o Open complex
calipers to form an ellipse
Amniotic Sagitt
Q1
Measure largest
pocket
clearthe
of fetal
around vertical
abdomen
including
skin
Fluid
al
components
linefrom Anterior to Posterior
Index
Sagitt
Q2 FL
Measure
vertical
pocket
clear
of fetal
Long
Femurlargest
bone with
distal
or end
shadowing
(volume)
al Bone
components
from technique
Anterior to Posterior
Measurement
Q1+Q2+ Sagitt
Q3
Measure
largest
vertical
pocket
of fetal
o Place calipers from
endclear
to end
on the
Q3+Q4=
al
components
from
Anterior
to Posterior
femur
-Do
not include
epiphysis point
AFI
o largest
Calipersvertical
shouldpocket
dissectclear
the middle
Measure
of fetalof
the from
boneAnterior to Posterior
components
*Structur
Sagitt
Long
HL
Humerus bone with distal or end
es seen
al Bone
Q4
shadowing
HMP:\Protocols\OBGYN Protocols\2nd Trimester
Protocol.docx
in each
Measurement technique
pocket
o Place calipers from end to end on the
will vary

2nd and 3rd Trimester OB Protocol

Organ/
Order

Thorax/
Abdomen

Stomach

Fetal Thorax, Abdomen and Pelvic Structures


Scan
Label
Landmarks Identified
Plane
RT lung
DIAPHRAG Diaphragm
Sagittal
Liver
M RT

Sagittal

DIAPHRAG
M LT

Transver
se

STOMACH

Transver
se

Kidneys

Sagittal

KIDNEYS

RK SAG

LT lung
Diaphragm
Stomach

Stomach
Transverse spine

Transverse spine
Right kidney
Left kidney

Left Sagittal Kidney (can be taken in


coronal)
Measurement technique
o Superior to inferior border
Left Sagittal Kidney (can be taken in
coronal)
Measurement technique
o Superior to inferior border
Transverse spine
Umbilical cord insertion into abdomen
Abdominal skin line
Umbilical cord projecting from abdomen

Sagittal

Umbilical
Cord

LK SAG

Transver
se

CI

Transver
se

CORD

Bladder/
Cord

Transver
se

Bladder

Transver
se

Free floating loop of umbilical cord


demonstrating 3VC

Iliac wings
Bladder
Color Doppler around bladder

BLADDER

Iliac wings
Bladder

GENDER

3VC

Male
o Scrotum and penis
Transver Protocols\2nd Trimester Protocol.docx
HMP:\Protocols\OBGYN
Female
Gender
(identify
se
o Labia
male or
female)

2nd and 3rd Trimester OB Protocol

HMP:\Protocols\OBGYN Protocols\2nd Trimester Protocol.docx

2nd and 3rd Trimester OB Protocol

Fetal Spine and Extremities


Organ/
Order

Scan
Plane

Label

Landmarks Identified

CSP SAG

Skull, cervical spine, and upper thorax


o Sagittal view not available coronal
is acceptable, label accordingly

Sagittal

TSP SAG

Distal neck, thorax, and upper abdomen


o Sagittal view not available coronal
is acceptable, label accordingly

Sagittal

LSP SAG

Lower abdomen to lower point of LSP


o Sagittal view not available coronal
is acceptable, label accordingly

Transvers
e
Transvers
e
Transvers
e
Longitudi
nal
Longitudi
nal
Longitudi
nal
Longitudi
nal
Longitudi
nal

CSP TX

Spine up-just below skull, skin line

TSP TX

Spine up-mid thorax, rib, skin line

LS-SP TX

Spine up-iliac wings, skin line

RT HUMERUS

Shoulder, humerus and elbow

RT
ULNA/RADIUS
RT HAND

Elbow, ulna, radius and wrist

Wrist and fingers (open and closed)

LT HUMERUS

Shoulder, humerus and elbow

LT
ULNA/RADIUS

Elbow, ulna, radius and wrist


connections

LT HAND

Wrist and fingers (open and closed)

RT FEMUR

Femur and knee

RT TIB/FIB

Knee, tibia, fibula and ankle


o FRONTAL View

Coronal

RT FOOT

Foot
Toes

Longitudi
nal

LT FEMUR

Femur and knee

Sagittal

Spine

Upper
Extremity

Lower
Extremity

Longitudi
nal
Longitudi
nal
Longitudi
nal

LT TIB/FIB
Knee, tibia, fibula and ankle
Longitudi
o FRONTAL View
nal
HMP:\Protocols\OBGYN Protocols\2nd
Trimester Protocol.docx
LT FOOT
Foot
Coronal
Toes

2nd and 3rd Trimester OB Protocol

Fetal Heart
Fetal heart images will vary from site to site. All students are responsible for
completing a sweep through the heart to determine situs, connection and
recognize views

Organ/Orde
r
Subcostal
4 Chamber
View

Apical
4 Chamber
View

Superior
Vena Cava
& Inferior
Vena Cava
Left
Ventricular
Outflow
Tract

Aortic Arch

Right
Ventricular
Outflow
Tract
Right
Ventricular
Outflow
Tract
Ductus
Arteriosus

Scan
Plane
Transverse
fetal chest
(IVS
horizontal)
Transverse
fetal chest
(IVS
Vertical)
Long axis
Sagittal
fetal chest

Long Axis
Transverse
fetal chest
Sagittal
Fetal
Chest

Long Axis
Transverse
Fetal
Chest
Short Axis
Transverse
Fetal
Chest
Sagittal
Fetal

Label

Landmarks Identified

Right and left atrium


Foramen Ovale
Right and left ventricle
Tricuspid and Mitral Valves
Spine

Right and left atrium


Foramen Ovale
Right and left ventricle
Tricuspid and Mitral Valves
Spine

SVC/IVC

Inferior vena cava


Right atrium
Superior vena cava

LVOT

Left ventricle
Aortic valve
Aortic root

Proximal aorta
3 branches-innominate, left common
carotid artery & left subclavian
Thoracic aorta

Right ventricle
Pulmonary valve
Pulmonary trunk

RT ventricle
Pulmonary valve
RT pulmonary artery
LT pulmonary artery
Aorta
Aortic valve
Pulmonary trunk
Ductus arteriosus

4CH
SUBCOST
AL

4CH
APICAL

AA

RVOT

RVOT
SHORT

DA

HMP:\Protocols\OBGYN Protocols\2nd Trimester Protocol.docx

Arch
3 Vessel
View

Chest
Transverse
Fetal
Chest

2nd and 3rd Trimester OB Protocol


Thoracic aorta
3 VESSEL
VIEW

AO
SVC
DA

Normal Measurement Ranges


Structure
Amniotic Fluid
Volume
Sum of 4
amniotic fluid
measurements

Area of
Interest
Divide the
uterus into 4
quadrants
and measure
the largest
vertical
pocket of
amniotic fluid
in each
quadrant

Plane
Sagittal

Measureme
nt
Greater than
20cm
abnormal
Less than
5cmabnormal

*measuremen

t may vary
per site

Amniotic Fluid
Largest Vertical
Pocket

Single

Sagittal

Greater than
10cmAbnormal

Less than

2cmAbnormal
*measuremen
t may vary
per site
Cerebellum

Posterior
Fossa of the
Brain

Sagittal

Nuchal Fold

Skin
thickness on
the posterior
head

Coronal

Equal to
gestational
age

Normal

-less than
6mm up to 24
weeks
gestation

Comments
Patient should be supine
With the probe in the
sagittal position, locate
the largest pocket of
amniotic fluid clear of all
fetal parts
Measure the fluid pocket
from anterior to posterior
(at least 1cm)
Document this
measurement for each
quadrant of the uterus.
Add the measurements
for a total
Measurement of the
largest single vertical
pocket of fluid in the
uterus
Commonly used for twin
pregnancies

Move caudal from BPD.


Head must be
symmetrical
Same plane as
cerebellum measurement

Anechoic
Coronal
Normal
Same plane as
Space in the
-less than 10
cerebellum measurement
Posterior
mm
Fossa
HMP:\Protocols\OBGYN Protocols\2nd Trimester Protocol.docx
Cisterna Magna

Kidney Length

Lateral
Ventricles

2nd and 3rd Trimester OB Protocol


Longest axis
Sagittal
Approximatel Long axis of the kidney
of the kidney
y equal to
measuring from superior to
gestational
inferior pole
age through
2nd trimester
Amount of
cerebrospinal
fluid in
ventricle

Coronal

Less than 10
mm

Superior to BPD at the


level of the ventricles
Measure at atrium or the
thickest portion of the
choroid plexus (CHP) or
glomus

Color and Spectral Doppler Analysis


Structure
Umbilical
Artery

Area of
Interest
Document
umbilical
artery blood
flow with Color
Doppler and
Spectral
Analysis in a
free loop of the
umbilical cord

Plane
Longitudi
nal

Normal
Measurement
S/D= less than
3 after 30 week

Comments

PI= less than


1.25 after 30
week

RI-less than .7
after 30 weeks

Umbilical
Vein

Middle
Cerebral
Artery

Document
umbilical
artery blood
flow with Color
Doppler and
Spectral
Analysis in a
free loop of the
umbilical cord
Lateral
branches of
the circle of
Willis

Longitudi
nal

Coronal

2nd-3rd
trimester=
Continuous
forward flow
with increasing
mean velocities
until 37 weeks

PI=

Greater than
1.45 before
term

Less than 1 by
term

HMP:\Protocols\OBGYN Protocols\2nd Trimester Protocol.docx

Angle correct is not


needed
Low resistive wave
form
High end diastolic flow
is normal
Absence of diastolic
flow indicates fetus is
in distress
Reversal of diastolic
flow is severe and seek
immediate help from
physician
Pulsations can indicate
a severe condition
Fetal breathing
movements will alter
continuous forward
flow pattern

Found slightly caudal


to BPD plane
Same proximal end
Position the head to
achieve a Doppler
angle of zero or as
close as possible
High impedance flow

2nd and 3rd Trimester OB Protocol


(Decreases

after 32 weeks)

Ductus
Venosus

Shunt between
the umbilical
vein and
inferior vena
cava

Transvers
e
Abdomen

Peak velocity=
50 cm/sec

with low diastolic flow


Abnormal flow will
display high diastolic
flow
Indicate pre-eclampsia,
IUGR & anemia
High diastolic
component
Evaluate the A waveabnormal if less than
5cm/sec

Laboratory Values
Qualitative hCG-urine pregnancy test, results positive or negative
Quantitative hCG- blood pregnancy test, results indicate possible age of pregnancy
Alpha Fetoprotein (AFP)-blood test for detection of certain abnormalities at 15-20 weeks
High indicates open neural tube defect
Low indicates Down syndrome
Abnormal in cases of wrong dates, fetal demise or twins
Triple Screen or Quad Screen-combination of blood test including AFP, unconjugated
estriol (uE3), hCG, and Inhibin A (Quad screen)
Used to detect chromosome abnormalities
Pathology
Gray scale sagittal and transverse images including images with 3 measurements
(length, width and height)
Color Doppler image document the presence of blood flow
Spectral Doppler image document type and velocity of blood flow

HMP:\Protocols\OBGYN Protocols\2nd Trimester Protocol.docx