USG Intensif 8. Fetal Biometry Based On ISUOG JJE 20080901

FETAL BIOMETRY
BASIC COURSE OF O&G ULTRASOUND FOR RESIDENTS

( ISUOG CURRICULUM )
Judi Januadi Endjun
Intensive Ultrasound Course
DIVISION OF MATERNAL AND FETAL MEDICINE

Department of Obstetrics and Gynecology
Gatot Soebroto Army Central Hospital / School of Medicine Veteran University– Jakarta
2008
Hanya untuk Pendidikan dan

JJE-13/07/2009 Kesehatan
MATERI AJAR INI HANYA
UNTUK DIPERGUNAKAN
DALAM KEGIATAN
PENDIDIKAN DAN
KESEHATAN

RSPAD GATOT SOEBROTO
DITKESAD

• 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
Barang siapa mengamalkan apa-apa yang ia ketahui, maka Allah SWT akan mewariskan
kepadanya ilmu yang belum diketahuinya, dan Allah SWT akan menolong dia dalam amalannya
sehingga ia mendapatkan surga. Dan barang siapa yang tidak mengamalkan ilmunya, maka ia
tersesat oleh ilmunya itu, dan Allah SWT tidak menolong dia dalam amalannya sehingga ia akan
mendapatkan neraka (sabda Rasulullah Muhammad SAW)
Ilmu lebih utama dari harta, ilmu adalah pusaka para Nabi, sedangkan harta adalah pusaka
Karun atau Fir’aun.
Ilmu lebih utama dari harta, karena ilmu akan menjagamu sementara harta malah engkau yang
harus menjaganya.
Ilmu lebih utama dari harta karena di akherat nanti pemilik harta akan dihisab, sedangkan
orang berilmu akan memperoleh syafaat.
Ilmu lebih utama dari harta karena pemilik harta bisa mengaku menjadi Tuhan akibat harta
yang dimilikinya, sedangkan orang berilmu justru mengaku sebagai hamba Tuhan karena
ilmunya.
Harta itu jika engkau berikan menjadi berkurang, sebaliknya ilmu jika engkau berikan malahan
semakin bertambah.
Pemilik harta disebut dengan nama kikir dan buruk, tetapi pemilik ilmu disebut dengan nama
keagungan dan kemuliaan.
Pemilik harta itu musuhnya banyak, sedangkan pemilik ilmu temannya banyak.
Harta akan hancur berantakan karena lama ditimbun zaman, tetapi ilmu tidak akan rusak dan
musnah walau ditimbun zaman.
Harta membuat hati seseorang menjadi keras, sedangkan ilmu malah membuat hati menjadi
bercahaya.
(hamba Allah)
JJE-13/07/2009 Hanya untuk Pendidikan dan
Kesehatan
FETAL BIOMETRY
• 1st Trimester
• 2nd Trimester
• 3rd Trimester

JJE-20090526
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 age estimation
• GS
• YS
• CRL
• BPD
• HC
• FL
• HL

Gestational Sac Diameter

Yolk Sac Diameter

CRL

Applications of Fetal Biometry in
the 2nd and 3rd Trimesters
 Monitoring fetal growth
 Detection of fetal anomalies
 Late gestational age assignment
 Fetal weight estimation

Hanya untuk Pendidikan dan Merz E, 2005
PRE-REQUISITES
• Gestational age : CRL, redating should be done
only once
• Equipment settings : velocity calibration, gain
setting, scale calibration
• Defining the reference plane : use standard
reference
• Defining the biometry points : outer to inner
and outer to outer ; measurement in late pregancy
• Use of growth charts : upper and lower limits
• Documentation
BASIC BIOMETRY
B. Cephalometry  Head : BPD , OFD,

HC
E. Abdominometry  Abdomen : ATD,

ASD, AC
H. Measuring the long
tubular bones  Limbs : FL, HL
J. Extended biometry

A. CEPHALOMETRY
• Parameters : BPD, OFD, HC
• Reference plane : transverse

occipito-frontal plane
• Technique : outer to outer (BPD,

OFD), outer to inner (BPD)
• Dolicho-cephalic head shape :

HC
• Growth curves : Indonesia Sumber: AIUM

HEAD AND NECK

Sumber: AIUM
Assessment of Gestational Age
• Should be accomplished at the time of
the initial scan using a combination of a
cranial measurement (BPD, HC) and limb
measurement (FL).
• 3rd trimester measurement may not

accurately reflect gestational age.

Assessment of Gestational Age
• Should be based on the earliest
examination : current fetal age = estimated
age at time of initial study – number of
weeks elapsed since first study
• Measurement of structurally abnormal fetal

body parts (head in hydrocephalus or limbs
in skeletal dysplasia) should not be used in
the calculation of estimated gestational age
Merz E, 2005

The standard reference level for
measurement of the BPD is an axial image
that includes the thalamus
• Dolichocephalic or brachycephalic : the BPD measurement may be
misleading → use CI or HC
• Cephalic index (CI) : ratio of BPD to FOD (NORMAL : 75 – 85%)
• Linear relationship BPD and GA between 20 – 30 W : ± 9 days in

95% of pregnancies (Campbell, J Obstet Gynecol Br Cwlth, 1969)
• Hadlock et al (1982) : 36 – 42 W → 3.6 W
• Best : 12 – 18 W → GA : 89.4% (LMP : 69.7%)

BIPARIETAL DIAMETER
• Most popular and problematic
• Entire calvarium and appears ellipsoidlike
• Falx cerebri, anterior and posterior fossae

• Thalami : two triangular echo-free areas in the
midportion
• Septum cavi pellucidi : two short parallel lines

• 3rd ventricle : between the thalami, by a slitlike
appearance
BIPARIETAL DIAMETER
• Frontal horn of the lateral
ventricles, which is
separated by the septum
cavum pellucidum
• Outer to outer margin of

the parallel parietal bone
(RSPAD Gatot Soebroto
Hospital)

BIPARIETAL DIAMETER
• Linear relationship BPD and GA between
20 – 30 W : ± 9 days in 95% of pregnancies
(Campbell, J Obstet Gynecol Br Cwlth, 1969)
• Hadlock et al (1982) : 36 – 42 W → 3.6 W
• Best : 12 – 18 W → GA : 89.4% (LMP :

69.7%)

OCCIPITO-FRONTAL
DIAMETER (OFD)
• Same plane used for BPD
• Distance from the
midechogenic plane of the
occipital bone to the
midechogenic plane of the
frontal bone
• Anteroposterior resolution :
< 2 mm
• Lateral resolution : 3 – 5
mm
HC
• HC is measured at the
same level as the BPD,
around the outer
perimeter of the
calvarium

HC / AC Ratio

B. ABDOMINOMETRY
• Parameters : ATD, ASD, and AC (outer-to-

outer)
• Growth curve : Indonesia
• Head/trunk ratio : IUGR; micro or

macrocephaly → BPD/ATD or HC/AC

ABDOMINOMETRY
• Reference plane : umbilical vein (UV) enters the
portal sinus
• Locating the reference plane : fetal trunk in a

transverse scan perpendicular to the long axis; the liver,
stomach, and UV are identified; approximately circular; and
the UV appears only as a short vascular segment within the
liver
• Pitfalls : full length of the UC,and pressing too

hard
Abdominal Circumference

AC chart

AC

5. Fetal weight should be estimated in the
late 2nd and in the 3rd trimesters and
requires the measurement of AD or AC

5A. AC should be determined on a true
transverse view, preferably at the level
of the junction of the left and right portal
veins
• EFW : IUGR or Macrosomia

5B. If previous fetal biometric studies have been performed, an estimate of
the appropriateness of interval growth should be given
Hanya untuk Pendidikan dan JJE-20071022

Estimation Of Fetal Weight
• BPD
• AC
• FL
• Volumetry
Fetal weight should be estimated in the
late 2nd and in the 3rd trimesters and
requires the measurement of AD or AC

EFW chart

Bambang Karsono, 1988 Hanya untuk Pendidikan dan
C. MEASURING THE LONG
TUBULAR BONES
• Indications : Early detection or exclusion of

skeletal dysplasias; Gestational age : microcephaly,
IUFD
• Parameters : ossified shaft, consisting of the

diaphysis and metaphysis; the epiphyses are
ignored; the curvature is also ignored
• Technique : sound beam perpendicular to the long

axis of the bone (if possible), the ends of the bones
are sharply defined
MEASURING THE LONG TUBULAR
BONES
• Growth Curves : the majority of growth curve

have been plotted to the femur; the other long
bones is still reserved for extended biometry; and
almost linear growth rate in the 2nd trimester,
followed by a declining rate in the third trimester.
• Bone disorders : high degree of confidence

4C. FL should be routinely measured and
recorded after the 14th weeks
• There is considerable biological

variation in normal FL late in
pregnancy

Femur Length measurement

FL curve

D. EXTENDED BIOMETRY
(ORGAN BIOMETRY)
For the purpose of addressing a specific

issue :
2. Head and Neck
3. Thorax
4. Abdomen and Pelvis
5. Specific Bone Measurement
6. Other Measurement
D.1. HEAD and NECK :
Cerebral Ventricles
• Biometry points : hydrocephalus, measurements of
the lateral ventricles can be taken at the level of the
frontal horns, pars centralis, or occipital horns; the frontal
measurements are the easiest to perform
• Technique : the lateral ventricles measured directly
• Normal values : pars centralis < 13 mm; bifrontal

ventricular width 11 mm at 13 W and 24 mm at term; the
ratio of bifrontal ventricular width to BPD was 0.48 at 13
W and 0.25 by term
HEAD and NECK :
Cerebral Hemispheres
• Hemispheric width : distance from the midline echo to
the inner table of the calvaria
• Ventricle-hemispheric ratio : at the pars centralis;

0.56 at 15 W to 0.28 at term
• Garret (1979) : V/H ratio > 0.5 after 18 W is proof of

hydrocephalus
• Evidence for hydrocephalus is not conclusive until

21 W
Anterior Cerebral Ventricle
Diameter

Posterior Cerebral Ventricle
Diameter

Ratio Va / H

Ratio Vp / H

HEAD and NECK :
Cavum Septi Pellucidi
• Slit-like hypoechoic cavity, on the anterior

midline, inferior to the corpus callosum
• Uniform increase between 19 – 27 W,

followed by a plateau until term
• > 10 mm : cerebral dysfunction, ↑ MR, developmental

delay, and neuropsychiatric disorders
HEAD and NECK :
Cerebellum
• Transverse cerebellar diameter (TCD)
• Measured by tilting the occipitofrontal plane

downward until the cerebellum appears (bilobed
structure in the posterior fossa)
• The CSP can still be seen
• Equal to the week 12 – 22 (useful for GA)

Transverse Cerebellar Diameter

HEAD and NECK :
Cisterna Magna
• Measured in the same plane as the
cerebellum
• The growth curve is initially linear and

declines toward the end of the pregnancy
• Abnormal > 10 mm : trisomy 18 or 13
• DD : Dandy-Walker malformation
Cisterna Magna

HEAD and NECK :
Nuchal Fold in the 2nd Trimester
• The skin and subcutaneus tissue in the nuchal
area (outer to inner)
• Should not exceed 5 mm in diameter between

15 – 20 W
• ↑ Risk of trisomy 21
• Reference plane : same with cerebellum

measurement Hanya untuk Pendidikan dan
HEAD and NECK : Orbita
• Orbital diameters
• Inner inter-orbital distance
• Outer inter-orbital distance
• 13 W : coronal scan, angled coronal scan, or

transverse scan
• Nonlinear pattern of growth
• Facial dysmorphia, orbital asymmetry, hypo-or-

hypertelorism
D.2. THORAX
Thoracometry :
• fetal thoracic measurements on the
cardiac plane;
• bony thorax (initially linear growth) and

oblique lung diameter (slight decline by
just 12 W);
• detect pulmonary hypoplasia as early as

24 W
THORAX
Heart :
• 4CV;
• ratio of transverse cardiac diameter to transverse

thoracic diameter is 0.52 ;
• M-mode and cine-loop : precise evaluation of

ventricular width during diastole and systole, a
tracing is obtained at the level of the AV-valve,
perpendicular to the IVS, and AV-valve are closed at
the end of diastolic
D.3. ABDOMEN AND PELVIS
• Liver • Bowel
• Gallbladder • Kidneys
• Spleen • Adrenal Glands
• Pancreas • Bladder
• Stomach

D.4. SPECIFIC BONE
MEASUREMENT
• Clavicle
• Rib Length
• Vertebral Bodies
• Foot

D.5. OTHERS MEASUREMENTS
• Nasal Width
• Bony nasal length
• Tongue circumference
• Shoulder rump length
• The length and circumference of the
thigh and lower lrg
• etc

THANK YOU


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FETAL BIOMETRY

BASIC COURSE OF O&G ULTRASOUND FOR RESIDENTS

Judi Januadi Endjun

Intensive Ultrasound Course

DIVISION OF MATERNAL AND FETAL MEDICINE

Hanya untuk Pendidikan dan

Hanya untuk Pendidikan dan

Hanya untuk Pendidikan dan

Hanya untuk Pendidikan dan

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

Hanya untuk Pendidikan dan

Hanya untuk Pendidikan dan

Hanya untuk Pendidikan dan

Hanya untuk Pendidikan dan

Hanya untuk Pendidikan dan

 Detection of fetal anomalies

 Late gestational age assignment

 Fetal weight estimation

B. Cephalometry  Head : BPD , OFD,

E. Abdominometry  Abdomen : ATD,

Hanya untuk Pendidikan dan Merz E, 2005

• Reference plane : transverse

• Technique : outer to outer (BPD,

• Dolicho-cephalic head shape :

• Growth curves : Indonesia Sumber: AIUM

Hanya untuk Pendidikan dan Merz E, 2005

Hanya untuk Pendidikan dan

• 3rd trimester measurement may not

Hanya untuk Pendidikan dan Merz E, 2005

• Measurement of structurally abnormal fetal

Hanya untuk Pendidikan dan

• Cephalic index (CI) : ratio of BPD to FOD (NORMAL : 75 – 85%)

• Linear relationship BPD and GA between 20 – 30 W : ± 9 days in

• Hadlock et al (1982) : 36 – 42 W → 3.6 W

• Best : 12 – 18 W → GA : 89.4% (LMP : 69.7%)

Hanya untuk Pendidikan dan

• Falx cerebri, anterior and posterior fossae

• Septum cavi pellucidi : two short parallel lines

• Outer to outer margin of

Hanya untuk Pendidikan dan

• Hadlock et al (1982) : 36 – 42 W → 3.6 W

• Best : 12 – 18 W → GA : 89.4% (LMP :

Hanya untuk Pendidikan dan

Hanya untuk Pendidikan dan

Hanya untuk Pendidikan dan

• Parameters : ATD, ASD, and AC (outer-to-

• Growth curve : Indonesia

• Head/trunk ratio : IUGR; micro or

Hanya untuk Pendidikan dan

• Locating the reference plane : fetal trunk in a

• Pitfalls : full length of the UC,and pressing too

Hanya untuk Pendidikan dan

Hanya untuk Pendidikan dan

Hanya untuk Pendidikan dan

Hanya untuk Pendidikan dan

Hanya untuk Pendidikan dan

Hanya untuk Pendidikan dan JJE-20071022

Hanya untuk Pendidikan dan

Hanya untuk Pendidikan dan

• Indications : Early detection or exclusion of

• Parameters : ossified shaft, consisting of the

• Technique : sound beam perpendicular to the long

• Growth Curves : the majority of growth curve