USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416

OBSTETRIC ULTRASOUND:
SCREENING AT 10 – 14 WEEKS
Judi Januadi Endjun
DIVISION OF MATERNAL AND FETAL MEDICINE
Department of Obstetrics and Gynecology

Gatot Soebroto Army Central Hospital
School of Medicine Veteran University– Jakarta
2009
MATERI AJAR INI HANYA
UNTUK DIPERGUNAKAN
DALAM KEGIATAN
PENDIDIKAN DAN
KESEHATAN
Hanya untuk Pendidikan dan

JJE-13/07/2009 Kesehatan
• Jalani hidup ini dengan sabar, jujur
dan ikhlas,
• Mau mengerti dan melaksanakan
tatacara (adab) yang benar, dan
• Mempunyai kemauan untuk selalu
berbuat baik memperbaiki diri dan
lingkungan, serta membuat orang lain
JJE-13/07/2009
lebih baik
Kesehatan
Objectives of 1st Trimester US
Examinations
• Pregnancy dating
• Location and gestational age determination.
• Detection of embryo and or fetal life
• Normal early pregnancy
• Evaluation of pregnancy complications
• Detection of anomalies
• Detection of multiple pregnancy
• Evaluation of pelvic mass, IUD, etc

J. Wisser, 2005
Normal Early Pregnancy
• Physical and physiological changes.

• Embryo and fetal development.
• Technique : transabdominal, transvaginal (the

method of choice), transrectal, or transperineal.
• Transducer selection
• Informed consent : very important

1 14- 19 22 25 29 32 35
15
LMP Ovulation Uterine HCG (+) USG (+) > 1800

- cavity Implan >10 >400 mIU/ml
Fertilizati tation mIU/ml mIU/ml
JJE-13/07/2009
on Kesehatan
AIUM Guidelines for 1st
Trimester Ultrasound
1. The uterus and adnexa should be evaluated for the
presence of a gestational sac (GS). If GS is seen, its
location should be documented. The presence or
absence of an embryo should be noted and CRL
recorded
3. Presence or absence of cardiac activity should be

reported
5. Fetal number should be documented
7. Evaluation of the uterus, adnexal structures, and cul-de-

sac should be performed
AIUM Guidelines 1 :
• CRL is a more accurate indicator of GA than GS
diameter.
• Identification of a YS or an embryo is definitive

evidence of a GS.
• Intrauterine fluid collection can sometimes represent

pseudogestational sac associated with ectopic
pregnancy
• During the late 1st trimester, BPD and other fetal

measurements also may be used to establish fetal age

AIUM Guidelines 2 :
• Real time observation is critical for this
diagnosis.
• With vaginal scan, cardiac motion should be

appreciated by a CRL of ≥ 5 mm.
• If an embryo < 5 mm is seen with no cardiac

activity, a follow-up scan may be needed to
evaluate for fetal life.
AIUM Guidelines 3 :
• Multiple pregnancies
• Pseudo GS : incomplete fusion between the
amnion and chorion, or elevation of the chorionic
membrane by intrauterine hemorrhage

AIUM Guidelines 4 :
• Recognition of incidental findings : myomas,
adnexal mass, fluid in the cul-de-sac or the flanks and
subhepatic space
• Correlation of serum hormonal levels with US

findings often is helpful for diagnosis of EP or
normal pregnancy

BIOMETRICS PARAMETER
< 5 weeks 5 weeks 6-10 weeks 10-12 weeks > 12 weeks
GS GS CRL C BPD
RLB
(Yolk sac) FL
PD
etc

Bambang Karsono
Gestational Sac
• The earliest ultrasonic confirmation
of an intrauterine pregnancy
• Usually visualized from 31 days or

4+3 weeks, 2 – 3 mm in diameter
• Circular transonic area surrounded

by a thick bright ring, usually lies at
uterine fundus, and eccentrically
placed (important markers for
confirming an intrauterine
pregnancy)
Trish Chudleigh, 2004
Yolk Sac
• Circular transonic mass within the GS
• Measurement from mid to mid (Blaas, 2008)
• First be identified transvaginally at about 35
days (3 – 4 mm in diameter)
• Grows slowly, maximum diameter of 6 mm at 10
weeks
• Identification of the YS difficult after about 12
weeks
• Correlation between YS morphology and the
outcome of pregnancy is not clear
1 YS
JJE-20071022
Yolk Sac
• Size, shape, and

location
• Normal : rounded,
diameter 3 – 6 mm, fixed
• Abnormal : not rounded,

diameter < 3 mm or ≥ 8
mm, and floating inside
GS.
THE EMBRYO
• Embryonic period : from
conception to the end of the 9th
postmenstrual week
• Fetal period : from 10th weeks
• TVS : 37 days, bright linear echo,

adjacent to the YS, close to the
connecting stalk, and the CRL 2
mm
• Grows at around 1 Hanya

mm per day
untuk Pendidikan dan
CROWN-RUMP LENGTH (CRL)
• < 50% of women are certain about
their menstrual dates
• IVF : the most accurate method
• CRL : as soon as the embryo can be
seen → unflexed, and longitudinal
section
• A discrepancy between certain
menstrual dates and CRL might
indicate an early IUGR
• CRL taken between 5 – 7 weeks or >
12 weeks are inaccurate
4 WEEKS PREGNANCY
+
• GS 2 – 5 mm is seen within the

endometrium
• Spherical, regular in outline, and

eccentrically situated towards the
fundus
• Implanted just below the surface of the

endometrium (midline echo), and is
surrounded by echogenic trophoblast
• If YS not visible → repeated in 1 week

5th Week of Menstrual Age
(Day 15 – 21 Postconception)
Observed under microscope : IVF/ET,
ICSI
Chorionic sac : 16 day post conception,
2 mm. Day 18 : 4 mm, YS can be seen
The chorion : circular echogenic
structure bordering directly on the
decidua
HRCD imaging can define maternal
blood vessels between the decidua
and chorion
J. Wisser, 2005

• A hypoechoic structure in the uterine cavity can be

identified as a chorionic sac only if it is surrounded by
hyperplastic endometrium and displays an echogenic
border, the chorion frondosum
• If these signs are disregarded, a fluid collection in the

uterine cavity (= pseudogestational sac) in an ectopic
pregnancy may be misinterpreted as an intrauterine
pregnancy
• If mean GS diameter > 12 mm and YS can’t be seen →

suspect anembryonic pregnancy → repeated in 1 week
(Chudleigh T, 2004)
J. Wisser, 2005
(Day 22 – 28 Postconceptional)
• Fetal pole : can usually be seen adjacent to the YS, echogenic
structure about 1 mm long on the surface of the YS
• Notochord : pear shaped appearance in coronal section and

contains a central notochord. The neural tube begins to close
from the rostral direction. These process concludes on day 38 of
menstrual age with closure of the inferior neuropore
• Heart activity : 23rd day post conception, consistently after 26th

day. The development of the cardiac pump and vascular system
are parallel

J. Wisser, 2005
(Day 22 – 28 Postconceptional)
• The embryo changes from being straight
line at the top of YS to being kidney-
bean-shaped, with the YS separated
from the embryo by the vitelline duct
• CRL : 4 – 10 mm
• IF FHR is not detectable → miscarriage ?

CARDIAC ACTIVITY
• CRL ≥ 7 mm should visible
FHR
• Rapid ↑ of the mean FHR

between 6-9 W followed by
a slight decline after 10 W
• Late onset and ↓ FHR in

the 1st trimester → higher
rate of spontaneous
abortion
• Separation from the YS : 4 mm embryo, rostral pole
begins to fold away from the YS, still broadly
adherent to the YS.
• After development of the connecting stalk, the

embryo increasingly separates, the YS is
extruded into the extra-amniotic coelom.
• Only the vitelline duct connecting it to the

embryonic vascular system
J. Wisser, 2005
Brain : rapid development and comprises ± 50%
of the total body length, body length 9 mm, two
cardiac chamber separated by a distinct IVS. At
36 day CA, body movement can be detected
(reflect the CNS function).
Telencephalon : day 40 CA, rostral, symmetrical

outpouching from the prosencephalon & later
envelops the diencephalon.

J. Wisser, 2005
• Limb differentiation : embryo length 16 mm, changes external body
shaped, characterized by longitudinal growth & differentiation of the
limbs. Differentiation of the upper limbs precedes that of the lower
limbs by several days
• Physiologic umbilical hernia : sagittal scan through the UC insertion,
hyperechoic structure located in front of the abdominal wall
• Heart : completes its complex structural development. The ostium
primum regress & the membranous IVS closes, completely
separating the systemic circulation from the pulmonary circulation.
Increase epimyocardial mantle, steady rise in HR
• Brain : the head begins more upright position. The midbrain flexure &
dominant rhombencephalic fossa are clearly visible in a midsagittal
scan
J. Wisser, 2005
10 – 12 WEEKS PREGNANCY

12 WEEKS

Clinical Importance of Ultrasound Embryology :
Developmental milestones in the 1st trimester
Ultrasound Finding Earliest Visualization Definite Visualization

(Menstrual Age) (Menstrual Age)
Chorionic cavity Day 30 Day 32

Yolk Sac Day 32 Day 34
Fetal pole Day 35 Day 37
Heart activity Day 37 Day 40
Limbs Day 47 Day 53
Telencephalon Day 50 Day 54
Movements Day 50 Day 56
Stomach Week 10 Week 11
Urinary bladder Week 11 Week 12
Genitalia Week 12 Week 14

J. Wisser, 2005
1 Trimester screening
st
• Soft markers chromosomal anomalies : golf ball (echogenic foci intra

cardiac), NT, echogenic bowels, nasal bone, and TR
•Anensefalus
•Hidrosefalus

JJE-20071022
1st Trimester screening
• Yolk sac (shape, size, and number)
• Nuchal translucency (NT)

Nuchal Translucency (NT)
• Enlargement (> 3 mm) is associated with chromosomal
abnormalities
• Different from cystic hygroma associated with Turner’s
syndrome; cystic hygromas usually have septations
• The membrane represents skin elevated from the nuchal
area, possibly related to a cardiac malformation or edema
• If present, there is high association with chromosomal
abnormality.
• Detection and evaluation of NT require meticulous
scanning, usually using a transabdominal approach

(Arthur C. Fleischer, 2004)
Hanya untuk Pendidikan dan Sumber; ISUOG, 2002
JJE-20071022 Sumber : ISUOG, 2002
Nasal Bone
• Examination of the nasal bone
• The GA should be 11-13+6 weeks and

the fetal CRL should be 45 - 84 mm.
• The image should be magnified so that

the head and the upper thorax only are
included in the screen.
Nasal Bone
• A mid-sagital view of the fetal profile should be
obtained with the ultrasound transducer held in
parallel to the direction of the nose.
• In the image of the nose there should be three distinct

lines.
• The top line represents the skin and the bottom one,
which is thicker and more echogenic than the
overlying skin, represents the nasal bone. A third line,
almost in continuity with the skin, but at a higher level,
represents the tip of the nose.
Fetal medicine
Sumber: ISUOG

hypoplasia absent

JJE-13/07/2009 Kesehatan Sumber: ISUOG
PREGNANCY FAILURE
• Pre-embryonic : > • GS (+) : 11,5%

50% • YS (+) : 8,8%
• Embryonic : 28% • Embryo ≤ 5 mm :
• Fetus : 10% 7,1%
• 7-9 weeks : 5% • Embryo 5-10% :
• 10-12 weeks : 1 – 2% 3,3%
• Embryo ≥ 10 mm :
0,5%

ETIOLOGY OF PREGNANCY FAILURE
• Pre-embryonic : 70% chromosomal abnormalities
• Embryonic : 56% chromosomal abnormality
• Fetus : placentation abnormality, perfusion

disturbances, uterine defect : uterus subseptus (↑ 4,7
x) , uterus arcuatus (↑ 5,8 x), uterus septus, maternal
disease(s), cervical incompetent.
• Antibody antinuclear : Uterine artery Pulsatility Index

↑
• Progesterone ↓
Problems of Early Pregnancy
1. Hormone measurement 1 Pregnancies of
: hCG unknown location
2. Miscarriage and IUFD 2 Twins pregnancy
3. Ectopic pregnancy 3 Trophoblastic disease
4. Cervical pregnancy 4 Ovarian problems
5. Ovarian pregnancy 5 Uterine fibroids
6. Abdominal pregnancy 6 Pregnancy and IUD
7. Heterotopic pregnancy 7 Screening fetal
anomaly
8 Organization of early
pregnancy unit

Miscarriage and IUFD
Embryonic death (FHR negative) RCOG
guidelines (1995) :
 CRL > 6 mm
 YS (-)
 GS > 20 mm
 If CRL < 6 mm or GS < 20 mm → rescan in
1 week
IUFD
• Causes : placental (48.4%), fetal
(22%), maternal (2.3%), placental &
maternal (1%), placental & fetal
(12.8%), and indeterminate (13.7%)
(Volker, 1992 ; Merz, 2005)
• Placental causes : chronic

insufficiency (54%), abruption
(24.5%), chorioamnionitis (24.5%),
subclinical intervillositis (2.1%),
and other causes & combinations
(3.2%) (Merz, 2005)
Blighted Ovum
• Thin and irregular wall
• No fetal echo at 25 mm of GS
• Subchorionic bleeding
• Serial US examination
• Compare with serum HCG

Subchorionic bleeding
• Hypoechoic and irregular
area subchorion
• Regularity of chorion wall,

fetal location, fetal life, and
uterine anomaly
• Sizing the bleeding area
• Serial US examination
Ectopic pregnancy
• Clinical conditions which increase risk of EP include
the presence of a scarred tube from salpingitis/PID
and/or previous tubal surgery
• TVS : no GS within uterus. Uterus size is normal or
slightly enlarged . 85% in initial US scan (Chudleigh T, 2004)
• Extrauterine extraovarian adnexal mass,

pseudogestational sac (10 – 29% of EP : Chudleigh T, 2004),
and hemoperitoneum
• The EP is usually on the side of the CL : ± 78% (Chudleigh
T, 2004)
• Living embryo outside of the uterus
Arthur C. Fleischer, 2004
Multiple pregnancy
• The numbers of GS
• Amniotic band
• Thickness of amniotic band
• Fetal echo : be careful vanishing
twin
• Fetal live and gestational age
• Anomaly
• Adnexal mass

Molar pregnancy
• Early in trophoblastic disease,
may appear as thickened,
irregular tissue within uterus.
• After ± 12 W, hydropic villi can be

recognized as punctate cystic
areas. (Arthur C. Fleischer, 2004)
• May be associated with theca

lutein cysts (septated cystic
adnexal masses). (Arthur C. Fleischer,
2004)

Partial Hydatidiform Mole
• Focal swelling of the villous tissue
• Focal trophoblastic hyperplasia
• Embryonic or fetal tissue
• Complete mole + fetus → molar placenta will be

clearly separated from the normal placenta
• Partial moles → molar structures are dispersed

inside the placental mass
Choriocarcinoma
• Highly malignant
• Multiple metastases
• The primary tumor is often very small

Pregnancy and Endometrial Cyst

Pregnancy and IUD
2002-07-10-08 Pregnancy and IUD © Sosa www.TheFetus.net

Down Syndrome

Echogenic bowels

Anencephaly
• TVS can be used

to detect
anencephaly as
early as 7-8 W
• TAS : 12 – 14 W

Doppler study
• Uterine artery Doppler :

notching → IUGR,
preeclampsia, IUFD
• Only for HRP
• Detection of heart beat
• Blood flow study

Diagnostic Procedures in the
1 Trimester
st
• CVS : under continuous sonographic visualization of

the catheter in which chorionic villi are aspirated from
the developing placenta.
• Early Amniocentesis : an aspiration needle is guided

into the amniotic fluid under continuous sonographic
guidance. It is sometimes difficult to puncture both
chorion and amnion in 13 – 16 W pregnancies
• Retrieval of tissue for karyotyping

CVS and Early Amniocentesis

CONCLUSIONS
• TVS has a vital role in the evaluation of patients
presenting with hemorrhage, distinguishing a
pregnancy with subchorionic hemorrhage from an
ectopic pregnancy or failed IUP. (Arthur C. Fleischer, 2004)
• TVS can accurately detect ectopic gestational sacs in

most cases. (Arthur C. Fleischer, 2004)
• Determine the objectives of 1st trimester ultrasound.

CONCLUSIONS
• Use the appropriate transducer and the route of
examination.
• Minimize side effects.
• CPD very important for maintaining personal

competence
• Good evidence that dating by ultrasound is more

accurate than even a reliable menstrual history in the
majority of cases (Chudleigh T, et al, 2004)
• 3D and Doppler examinations should be performed if

there indicated.
THANK YOU


USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416

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OBSTETRIC ULTRASOUND:

Judi Januadi Endjun

DIVISION OF MATERNAL AND FETAL MEDICINE

Department of Obstetrics and Gynecology

Hanya untuk Pendidikan dan

Hanya untuk Pendidikan dan

• Physical and physiological changes.

• Technique : transabdominal, transvaginal (the

• Informed consent : very important

LMP Ovulation Uterine HCG (+) USG (+) > 1800

3. Presence or absence of cardiac activity should be

5. Fetal number should be documented

7. Evaluation of the uterus, adnexal structures, and cul-de-

• Identification of a YS or an embryo is definitive

• Intrauterine fluid collection can sometimes represent

• During the late 1st trimester, BPD and other fetal

Hanya untuk Pendidikan dan

• With vaginal scan, cardiac motion should be

• If an embryo < 5 mm is seen with no cardiac

Hanya untuk Pendidikan dan

• Correlation of serum hormonal levels with US

Hanya untuk Pendidikan dan

< 5 weeks 5 weeks 6-10 weeks 10-12 weeks > 12 weeks

Hanya untuk Pendidikan dan

• Usually visualized from 31 days or

• Circular transonic area surrounded

• Size, shape, and

• Abnormal : not rounded,

• Fetal period : from 10th weeks

• TVS : 37 days, bright linear echo,

• Grows at around 1 Hanya

• GS 2 – 5 mm is seen within the

• Spherical, regular in outline, and

• Implanted just below the surface of the

• If YS not visible → repeated in 1 week

Hanya untuk Pendidikan dan

• A hypoechoic structure in the uterine cavity can be

• If these signs are disregarded, a fluid collection in the

• If mean GS diameter > 12 mm and YS can’t be seen →

• Notochord : pear shaped appearance in coronal section and

• Heart activity : 23rd day post conception, consistently after 26th

Hanya untuk Pendidikan dan

• IF FHR is not detectable → miscarriage ?

Trish Chudleigh, 2004

Hanya untuk Pendidikan dan

• Rapid ↑ of the mean FHR

• Late onset and ↓ FHR in

• After development of the connecting stalk, the

• Only the vitelline duct connecting it to the

Telencephalon : day 40 CA, rostral, symmetrical

Hanya untuk Pendidikan dan

Hanya untuk Pendidikan dan

Hanya untuk Pendidikan dan

Ultrasound Finding Earliest Visualization Definite Visualization

Chorionic cavity Day 30 Day 32

Hanya untuk Pendidikan dan

• Soft markers chromosomal anomalies : golf ball (echogenic foci intra

Hanya untuk Pendidikan dan

Hanya untuk Pendidikan dan

Hanya untuk Pendidikan dan

• Examination of the nasal bone

• The GA should be 11-13+6 weeks and

• The image should be magnified so that

• In the image of the nose there should be three distinct