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Obstetrical Ultrasound
Introduced in the late 1950s
ultrasonography is a safe, noninvasive, accurate and cost-effective
means to investigate the fetus
Computer generated system that uses
sound waves integrated through real
time scanners placed in contact with a
gel medium to the maternal abdomen
The information from different
reflections are reconstructed to
provide a continuous picture of the
moving fetus on the monitor screen
Obstetrical Ultrasound
Indications:
Unsure last menstrual period
Vaginal bleeding during pregnancy
Uterine size not equal to expected for dates
Use of ovulation-inducing drugs confirm early pregnancy
Obstetric complications in a prior pregnancy: ectopic, preterm
delivery
Screen for fetal anomaly: abnormal serum screens, certain drug
exposure in early pregnancy, maternal diabetes. Rh
isoimmunization
Postdate fetus
Twins (monochorionic)
Intrauterine growth restriction (IUGR)
Obstetrical Ultrasound
Obstetrical Ultrasound
Pre and peri-ovulation (1-2 weeks): ovarian
follicle matures and ovulation
Conceptus (3-5 weeks): Corpus luteum,
fertilization, morula, blastocyst, bilaminar
embryo
Embryonic (6-10 weeks): Trilaminar Cshaped embryo
Fetal Phase: (11-12 weeks):
Obstetrical Ultrasound
(TVU)
Gestational sac: seen at 4 weeks, fluid
filled with echogenic border, grow at least
0.6 mm daily.15
Yolk sac: 33 days (4.7 wk)
Embryonic echoes: 38 days (5.4 w) with
embryo at 6 wk
In a normal pregnancy, the embryo should
be visible if the gestational sac is 25 mm
or larger in diameter.
Obstetrical Ultrasound
An intrauterine gestational sac should be visualized by
transvaginal ultrasound with -hCG values between 1000
and 2000 IU and abdominal exam 5500-6500 IU
Visible heart activity: 43 days (6.1w)
Normal heart rate at 6 weeks: 90-110 bpm
At 9 weeks:140-170 bpm.
At 8-9 weeks if nl heartbeat: no bleeding 3%loss
bleeding 13% loss
At 5-8 weeks a bradycardia (<90 bpm) is associated with a
high risk of miscarriage.
Obstetrical Ultrasound
CRL(Crown Rump Length):
Longest length excluding
limbs and yolk sac
Made between 7 to 13 weeks
3 days: 7-10 weeks
5 days: 10-14 weeks
Fetal CRL in centimeters plus
6.5 equals gestational age in
weeks
Obstetrical Ultrasound
Ultrasound findings in a
pregnancy destined to abort
include:
A poorly-defined, irregular
gestational sac
A large yolk sac (6 mm or
greater in size)
Low site of sac location in the
uterus
Empty gestational sac at 8
weeks' gestational age (the
blighted ovum).
Obstetrical Ultrasound
First Trimester Screening
In 2007, the American College of Ob Gyn endorsed offering
aneuploidy screening to all gravidas
Performed between 11 and 13 weeks 6 days (fetal crownrump
length 4279 mm).
Fetal nuchal translucency and maternal blood, -hCG and
pregnancy-associated plasma protein A (PAPP-A).
This test can detect approximately 60-85% of fetuses with
Down syndrome, with a 5% false positive rate.2
Abnormal screen can increase the risk of genetic, other
aneuploidies and other cardiac anomalies
Obstetrical Ultrasound
Nuchal translucency:
Translucent space between the back of the
neck and the overlying skin
The scan is obtained with the fetus in sagittal
section and a neutral position .
The fetal head (neither hyperflexed nor
extended, either of which can influence the
nuchal translucency thickness).
The fetal image is enlarged to fill 75% of the
screen, and the maximum thickness is
measured, from leading edge to leading edge.
(inner to inner measurement)
It is important to distinguish the nuchal
lucency from the underlying amnionic
membrane.
> 6 mm considered abnormal
Obstetrical Ultrasound
Amnionitic fluid
Placenta
Cervix
Fetal Anatomic screening
Obstetrical Ultrasound
Cervical length
Endovaginal probe, examine in dorsal lithotomy position
with empty bladder
Normal cervix should have a length of 2.5cm or more from
10 weeks gestation until 36 week
The width of the cervical canal at the level of the internal
os should be less than 4mm
Document any evidence of funneling
Optimal gestational age for cervical length assessment is
after 16 to 20 weeks gestation
Assessment 20-24 weeks best time evaluation PTD
Obstetrical Ultrasound
Transvaginal probe
Full bladder
Cervical Length:
internal os to external
os
Obstetrical Ultrasound
Funneling
(percentage): internal
os to end of funneling
over total cervical
length)
Obstetrical Ultrasound
BPD:
Greatest accuracy between 12-28 weeks
(better>14 wks.)
The plane for measurement of head circumference
(HC) and bi-parietal diameter (BPD)must include:
Cavum septum pellucidum
Thalamus
Choroid plexus in the atrium of the lateral
ventricles.
Measure outer table of the proximal skull to the
inner table of the distal
HC:
Measure the longest AP length
(BPD + OFD) X 1.62
Obstetrical Ultrasound
Abdominal circumference
Determined on transverse view
at the level of the junction of the
umbilical vein, portal sinus, and
fetal stomach
Measured from the outer
diameter to outer diameter
Multiply mean diameter by 3.14
Assessing fetal
weight/IUGR/macrosomia
Obstetrical Ultrasound
Femur Length (FL):
Aligning the transducer with the lower
end of the fetal spine and rotating
toward the ventral aspect of the fetus
Can measure from 10 weeks onward
Measurement origin to distal end of
shaft and shows two blunted ends
Do not include femoral head or distal
epiphysis
Femur image is at an angle of less than
30 degrees to the horizontal.
It increases from about 1.5 cm at 14
weeks to about 7.8 cm at term.
Humerus
Measured similarly
Obstetrical Ultrasound
Amnionitic Fluid
AFI: measure four quadrants
of largest verticle pocket
5-20 cm. nl, 6-8 cm.
borderline, <5 cm
oligohydramnios
Polyhydramnios is defined as
an amniotic fluid volume in
excess of 2000 mL. A single
pocket of fluid that is 8 cm or
larger
Obstetrical Ultrasound
Placenta:
Determining its upper and lower edges r/o
placenta previa
With increasing gestational age, the placenta
increases in echogenicity because of increased
fibrosis and calcium content.
This feature of placental maturation has led to a
grading of placentas from immature (grade 0) to
mature (grade 3).
Placentolmegaly
Diabetes, fetal hydrops, Rh isoimmunization
Small placenta:
Severe IUGR (symmetrical/asymmetrical)
Grade 0
Grade 1
Grade 3
Obstetrical Ultrasound
Abnormal placentas
Placenta Previa
found in approximately 5% of
second-trimester scans
If detected at 1519 weeks, it
persists in 12% of patients.
If it is detected at 2427
weeks, it may persist in up to
50%.
Obstetrical Ultrasound
Fetal anatomy:
Head
Obstetrical Ultrasound
The atrium of lateral
ventricles should be less
than 10mm in diameter
(best measured at the
occipital horn).
The choroid plexii should
be homogenous.
Small, and sometimes
multiple, choroid plexus
cysts are a common
finding on high resolution
equipment.
They are of doubtful
significance as an isolated
finding.
Obstetrical Ultrasound
Face:
Profile
Nasal
bone
Nose
Lips
Obstetrical Ultrasound
Thorax
Lung volumes
Diaphphram
r/o CCAM
Congenital
diaphragmatic hernia
Obstetrical Ultrasound
Fetal Circulation
Obstetrical Ultrasound
Some of the blood entering the
right atrium does not pass
directly to the left atrium
through the foramen ovale, but
enters the right ventricle and is
pumped into the pulmonary
artery.
In the fetus, there is a
connection between the
pulmonary artery and the aorta,
called the ductus arteriosus,
which directs most of this
blood away from the lungs
Obstetrical Ultrasound
Cardiac Anatomy
Four-Chamber View of the Heart
The ultrasound beam is directed
perpendicular to the midchest plane
at the level of the heart.
These chambers consist of the right
and left atrial and both ventricular
chambers
Corresponding valves between them
http://www.fetal.com/FetalEcho/04%20Standard.html
Obstetrical Ultrasound
Obstetrical Ultrasound
Sweep the transducer beam in a transverse plane from the level
of the four chamber view towards the fetal neck
Right Outflow Tract
Left Outflow Tract
Right outflow track comes
Comes off left ventricle
off right ventricle and bifurcates
continues into aortic arch
continues into pulmonary artery
and then to descending
aorta
Obstetrical Ultrasound
Detect Fetal Heart Rate
M-mode
Obstetrical Ultrasound
Abdomen /Stomach
(presence, size, and
situs)
Liver
Cord Insertion:
Ensure the abdominal wall
around the cord insertion
is intact
No bowel has herniated
into the cord.
3-vessel
Obstetrical Ultrasound
Kidneys/Bladder
Kidneys
Confirm the presence
and position of both
kidneys.
Look for the anechoic
renal pelvis.
The renal pelvis TS
diameter should be
less than 5mm.
Obstetrical Ultrasound
Abnormal
Renal:
urethral atresia: large fetal
bladder (bl), urinary
ascites (asc), and
hydronephrotic kidneys
Posterior urethral valves
with keyhole bladder
Obstetrical
Ultrasound
Spine:
Coronal or Sagital
of entire spine:
cervical
Thoracic
Lumbar
Sacral
Transverse
assessment of
entire spine
Obstetrical Ultrasound
Upper Extremities
Normal
Abnormal
Fist clenched
Phocomelia
Obstetrical Ultrasound
Lower Extremities:
Obstetrical Ultrasound
Abnormal Ultrasounds
Omphalocele
Gastrochesis
Obstetrical Ultrasound
Doppler Ultrasound
Blood flow characteristics in the fetal blood vessels can be assessed
with Doppler 'flow velocity waveforms
Diminished flow, particularly in the diastolic phase of a pulse cycle is
associated with compromise in the fetus.
Various ratios of the systolic to diastolic flow are used as a measure of
this compromise.
The blood vessels commonly interrogated include the umbilical artery,
the aorta, the middle cerebral artery, ductus venosus (DV) and
umbilical vein (UV)
Abnormal uterine artery Doppler velocimetry and pre-eclampsia, intrauterine growth retardation and adverse pregnancy outcomes.
Doppler Ultrasound
Ductus venosus leads directly into the vena cava to allows some blood
rich in oxygen and nutrients to be pumped out of the body without
passing through the capillary beds in the kidney.
Abnormal waveforms in the ductus venosus may be key to predicting
right heart failure in the hypoxic fetus and an important indicator of
imminent fetal demise (Kiserud 1991).
Reversed flow in the ductus venosus is an ominous sign.
Doppler Ultrasound
The umbilical artery is
evaluated measuring the
blood flow velocity at
peak systole (maximal
contraction of the heart)
and peak diastole
(maximal relaxation of
the heart)
These values are
computed into different
ratios like S/D or RI
Doppler Ultrasound
Predict fetuses at risk
for anemia or hydrops
especially Rh
alloimmunized
pregnancies
>1.5 MOM or ratios
can be used
Obstetrical Ultrasound
Three-Dimensional
Ultrasound3D
Display multiple longitudinal,
transverse, and coronal images.
Obstetrical Ultrasound
Abnormal 3D Images
Cleft lip
Cyclopia
Obstetrical Ultrasound
4D Ultrasounds that adds the element of
time to the 3D process.
Offers live images
Fetal changes like movement, kicking, reach
with hands and facial expressions can be
seen
Obstetrical Ultrasound
Obstetrical Ultrasound
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