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SUBJECT: OB GYNE TOPIC: BASIC SONOGRAPHY IN OBSTETRICS Lecturer: Dr.

Rex Poblete Transcriber:Jorge Editor: Aby Number of Pages:7 any abnormalities in the uterus and adnexal structures such as ovarian mass (most common: corpus luteum), myoma, etc. But the primary indicator of viability is the fetal heart tone for the 1st 10 weeks.

Sonography in Obstetrics - The real time image on the ultrasound screen is produced by sound waves reflescted back from the organs, fluids, and tissue interfaces of the fetus within the uterus. - Transducers convert electrical energy into sound waves that are emitted in synchronized pulses, then listen for the returning echoes. - Because air is a poor transmitter of high frequency sound waves, soluble gel is applied to the skin to act as a coupling agent. - Sound waves pass through layers of tissue, with different densities, and are reflected back to the transducer. - Dense tisseu (bone)- bright / white - Fluid dark/ anechoic - High frequency transducers yield better image resolution - Low frequency penetrate tissue more effectively The lower the frequency, the more penetration, but it will compromise the resolution. So during 1st term, nung maliit pa yung fetus, transvaginal ultrasoundung gamit. Since malapit ung probe sa mismong fetus, pwdeng gumamit ng high frequency (4-9 megahertz), kaya nagiging high din ung resolution = malinaw ung picture However, pagdating the 2nd term onwards, since di na pwde transvaginal ung ultrasound (occupied na ni baby ung uterus), sa surface ng abdomen na lang ung probe (which means more tissue in between the probe n fetus). So to get through the tissues (to increase penetration), kailangan mababa ung frequency (2nd T: 4-6mgHz, 3rd T: 2-5mgHz). But this will compromise the image quality. Kaya according to doc, minsan magtataka ung mothers bakit pag first trimester ultrasound and linaw ng picture, pero pag second trimester na lumalabo. Anembyonic blighted

Indications for First Trimester Ultrasound: Confirm an intrauterine pregnancy Evaluate a suspected ectopic pregnancy Define cause of vaginal bleeding Evaluate pelvic pain Estimation of gestational age Diagnose multifetal gestations Confirm cardiac activity Assist chorionic villous sampling, embryo transfer and localization and removal of IUD Assess for fetal anomalies Evaluate maternal pelvic masses/ uterine abnormalities Measure nuchal translucency Evaluate suspected gestational trophoblastic disease Gestational sac is seen by 5 weeks, and fetal echoes and cardiac activity by 6 weeks. Crown Rump length is the most accurate biometric predictor of gestational age. Embryonic demise If no fetal activity in real time ultrasound, it is an indicator of early intrauterine embryonic demise

Subchorionic hemorrhage The detachment of the placenta from the site of implantation A common finding in patients with vaginal bleeding/spotting and it is an indicator of an abortion

Nuchal translucency (NT) The patient 100% pregnant and intrauterine but no fetus in the gestational sac Eventually leads to collapsed gestational sac First introduced in 1992 as a screening fot fetal chromosome abnormalities Combined with the maternal age to provide effective method of screening for trisomy 21 It is measured in the sagittal plane between 11 and 14 weeks using precise criteria

Ist trimester ultrasound For the 1st trimester ultrasound is done to check for the viability of the fetus and to see if there are

Increased NT also assess risk for other chromosomal conditions with associated cardiac and skeletal abnormalities Measure the area b/w skin and subQ tissue, >3mm = abnormal

Pathophysiology of NT 1. Cardiac failure in association with abnormalities of the heart and great arteries 2. Venous congestion in the head and neck, due to constriction of the fetal body in amnion rupture sequence or superior mediastinal compression in diaphragmatic hernia or the narrow chest skeletal dysplasia 3. Altered composition of the extracellular matrix 4. Abnormal or delayed development of the lymphatics 5. Failure of the lymphatic drainage due to impaired fetal movement in various neuromuscular disorder 6. Fetal anemia or hypoproteinemia 7. Congenital infection, acting through anemia or cardiac dysfunction *Basically NT pertains to the problem mostly regarding the circulation whether venous, arterial or lkymphatics. NT - Nuchal Translucency

The nuchal translucency (NT) measurement is the maximum thickness of the subcutaneous translucent area between the skin and soft tissue overlying the fetal spine at the back of the neck. Calipers are placed on the inner borders of the nuchal space, at its widest portion, perpendicular to the long axis of the fetus. In this normal fetus at 12 weeks' gestation, the measurement is 0.9 mm. Basic ultrasound in second and third trimester 14 weeks up to 42 weeks 1. Indications for second trimester ultrasound 2. Components of second trimester 3. Biophysical profile

Screening is done at 11 to 14 weeks Cut-off value is 3 mm

Three types of sonographic evaluations during the Second- and Third-Trimester Evaluations Its components are listed in this slide including a survey of fetal anatomy, When multifetal gestations are studied, documentation includes the number(s) of chorions and amnions, comparison of fetal sizes, estimation of amnionic fluid volume in each sac, and description of fetal genitalia if visualized. Fetal anatomy may be adequately assessed after approximately 18 weeks. If a complete survey of fetal anatomy cannot be obtainedfor example, due to oligohydramnios, fetal position, or maternal obesitythe limitation should be noted in the report

Components of SECOND and THIRD TRI Standard Ultrasound Examination


1.
2. 3. 4. 5. 6. 7. 8. 9.

Fetal number; multifetal gestations: amnionicity, chorionicity, fetal sizes, amnionic fluid volume, and fetal genitalia, if visualized Presentation Fetal cardiac activity Placental location and its relationship to the internal cervical os Amnionic fluid volume Gestational age Fetal weight Evaluation of the uterus, adnexa, and cervix Fetal anatomical survey, including documentation of technical limitations
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Placenta grading (Grannum) 0 = smooth chorionic plate on the fetal surface of the placenta w/o calcification I = placenta with scattered bright echoes II = increased basal and comma-like echogenicities extending into the placenta from the indentations of the chorionic plate III = Extensive basal, curvilinear echogenecities extending from the chorionic plate to the base of the placenta Amniotic Fluid Assesment AF plays an important role on assessing fetal growth, development and status Abnormal volume Can interfere with fetal structural development can signify an underlying disorder AF appearance Can determine fetal hypoxia (meconium staining) Sonographic Criteria 1. Subjective assessment 2. Single- pocket assessment (SVP) o For multiple gestation, cannot measure with umbilical cord o Oligohydramnios = less than 2 cm o Polyhydrmanios = more than 8 cm 3. Amniotic fluid index (AFI) o Most common o Oligohydramnios = less than 5 cm ( < 2.5th percentile) o Polyhydrmanios = more than 24 cm ( > 97.5th percentile) Oligohydramnios AFV= < 500cc = AFI is below 5cm = SVP is below 2cm = below the 10th percentile for age Etiology: - 2nd to a low fetal urine outout - Anatomic defects- potters syndrome, agenesis, PUV - IUGR and placental insufficiency

What is Polyhydramnios? AFV = 2 liters = AFI is above 24 cm = SVP is above 8 cm = AFI > 90th percentile for age Etiology: Maternal in 20% Fetal in 20% Idiopathic 60% Implication of polyhydramnios: Scan for anomalies of fetal upper GIT, CNS, and abdominal wall Treatment: 1. Amnioreduction/Amniocentesis 2. Oral indomethacin FETAL BIOMETRY Ultrasound parameters for fetal aging 1. Biparietal Diameter (BPD) The BPD is measured from the outer edge of the proximal skull to the inner edge of the distal skull, at the level of the thalami and cavum septum pellucidum more reliable when there is head shape change 2. Head Circumference (HC) The head circumference (HC) also is measured. If the head shape is flatteneddolichocephaly, or rounded brachycephaly, the HC is more reliable than the BPD.

Cephalic Index (CI) = BPD/OFD x 100 Dolichocephaly (flattened) = < 74 Brachycephaly (rounded) = > 83 3. Abdominal Circumference (AC) Has the largest reported variability Most difficult to obtain Accurate single predictor of growth disturbance Useful in calculating fetal weight The abdominal circumference (AC) has the widest variation, up to 2 to 3 weeks, because it involves soft tissue. This HB NOTES 109 | 3

circumference is most affected by fetal growth. The AC is measured at the skin line in a transverse view of the fetus at the level of the fetal stomach and umbilical vein 4. Femur Length (FL) The femur length (FL) correlates well with both BPD and gestational age. It is measured with the beam perpendicular to the long axis of the shaft, excluding the epiphysis, and has a variation of 7 to 11 days in the second trimester Easiest and most reproducible to measure The femur length (FL) correlates well with both BPD and gestational age. Measured with the beam perpendicular to the long axis of the shaft, excluding the epiphysis, and has a variation of 7 to 11 days in the second trimester

The outlier could result from poor visibility, but it could also indicate a fetal abnormality or growth problem. Sonography performed to evaluate fetal growth should typically be performed at least 2 to 4 weeks apart (ACOG, 2009; AIUM, 2007)

Key points in Biometry The variability of gestational age estimation increases with advancing pregnancy. Individual measurements are least accurate in the third trimester Estimates are improved by averaging the four parameters. If one parameter differs significantly from the others, it may be excluded from the calculation. HB NOTES 109 | 4

Ultrasound Features of Common High Risk OB Cases Molar pregnancy (H-mole) Placenta previa (Transvaginal Ultrasound more sensitive in the diagnosis) Abruptio placenta Preterm labor - Cervical funneling Preterm Labor TVS can be used to assess cervical status Thank Your Vaginal Ultrasound Determines the shape, length, and degree of shortening Shape of the Cervix

Doppler Velocimetry in Obstetrics The use of Doppler in obstetrics has been primarily in the areas of duplex velocimetry and color mapping. The Doppler shift is a phenomenon that occurs when a source of light or sound waves is moving relative to an observer and is detected by the observer as a shift in the wave frequency. When sound waves strike a moving target, the frequency of the sound waves reflected back is shifted proportionate to the velocity and direction of the moving target. Because the magnitude and direction of the frequency shift depend on the relative motion of the moving target, the velocity and direction of the target can be determined. Currently used to evaluate the fetus, placenta, umbilical cord, and uterine structures Significance: 1. Prediction of pregnancy-induced hypertension and IUGR 2. Assessment of fetal status in pregnancies complicated by diabetes, isoimmunization, fetal anomalies and multifetal pregnancies.

A T-shaped configuration of the internal os area with a diameter < 4 mms denotes cervical competence. Loss of the normal T-shape to either a Y, V or U shape denotes varying degrees of cervical incompetence.

Length of the Cervix A cervical length of 25 mm or less at 24-28 weeks gestation was significantly associated with preterm births at < 35 weeks of gestation.

Doppler systolicdiastolic waveform indices of blood flow velocity. The mean is calculated from computer-digitized waveforms. (D = diastole; S = systole.)

Percentage funneling = A / A+B Cervical Length mms (%) 22 26 30 35 ( 5) (10) (25) (50) RR (95% CI) of delivery at < 35 weeks AOG 24 weeks 28 weeks 9.49 13.88 6.19 9.57 3.79 5.39 2.35 3.52

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Blood vessels used for investigation Umbilical artery Uterine arteries Middle cerebral artery Ductus venosus Doppler waveforms from normal pregnancy. Shown clockwise are normal waveforms from the maternal arcuate, uterine, and external iliac arteries, and from the fetal umbilical artery and descending aorta. Reversed end-diastolic flow velocity is apparent in the external iliac artery, whereas continuous diastolic flow characterizes the uterine and arcuate vessels. Finally, note the greatly diminished end-diastolic flow in the fetal descending aorta. Umbilical artery Normally, with forward flow throughout cardiac cycle, the amount of flow during diastole increases as gestation advances S/D ratio decreases, from about 4.0 at 20 weeks to 2.0 at term S/D ratio is generally less than 3.0 after 30 weeks Considered abnormal if S/D ratio is above the 95th% for gestational age useful adjunct in the management of pregnancies complicated by fetal-growth restriction not recommended for screening of low-risk pregnancies or for complications other than growth restriction. Normal:

Reversed diastolic flow:

Significance! considered abnormal if the S/D ratio is above the 95th percentile for gestational age. In extreme cases of growth restriction, enddiastolic flow may become absent or even reversed(ARED) - almost half of cases are due to fetal aneuploidy or a major anomaly In the absence of a reversible maternal complication or a fetal anomaly, reversed enddiastolic flow suggests severe fetal circulatory compromise and usually prompts immediate delivery fetuses of preeclamptic women who had absent or reversed end-diastolic flow were more likely to have hypoglycemia and polycythemia (Sezik and colleagues, 2004) Uterine artery Typical - steep sytolic slope, an early diastolic notch, and a small amount of diastolic flow Starting at 14 weeks, disappearance of of notch and an increase of diastolic flow - fall in resistance index By 20 weeks, 15% retain a notch By 24 weeks, 5% have persistent notch Uterine FVW returns to nonpregnant state within days after delivery

Absent diastolic flow:

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At this time, MCA Doppler has not been adopted as standard practice in the management of growth restriction, and its utility in the timing of delivery of such fetuses is uncertain.

Significance! Failure of the uterine artery to modify (persistence of diastolic notch) implies that the placentation is defective, leading to the possible development of problems associated with poor placentation like pre-eclampsia, abruption, and IUGR Timing of investigation? Increased impedance of uterine artery velocimetry at 16 to 20 weeks was predictive of superimposed preeclampsia developing in women with CHVD Middle cerebral artery studied and employed clinically for detection of fetal anemia and in the assessment of growth restriction With fetal anemia = peak systolic velocity is increased due to increased cardiac output and decreased blood viscosity (Segata and Mari, 2004) Mari and colleagues (1995) performed MCA velocity studies in 135 normal fetuses and 39 with alloimmunization. They showed that anemic fetuses had a peak systolic velocity above the normal mean. Mari and colleagues (2000) used a threshold of 1.50 multiple of the median (MoM) for peak systolic velocity to correctly identify all fetuses with moderate or severe anemia. The falsepositive rate was 12 percent. In assessment of growth restriction= first is increased impedance of flow in the umbilical artery followed by redistribution of flow to the brain, with decreasing resistance that has been termed brain sparing, eventually by abnormalities in venous flow.

Ductus venosus In the setting of severe fetal-growth restriction, cardiac dysfunction may lead to venous flow abnormalities, including pulsatile flow in the umbilical vein and abnormal ductus venosus waveforms (Reddy and associates, 2008) Ductus venosus abnormalities may identify preterm growth-restricted fetuses that are at greatest risk for adverse outcomes 3D Ultrasound Clinical application: Morphology, malformation, agenesis (3D, easier in 4D) Bone shape abnormalities: spina bifida, dwarfism, club feet on one image, cleft palate vs. cleft lip Skeletal dysplasia abnormalities in dynamic 4D; investigation of spine Frontal bones, spatial view of fusion or not Variety of fetal volume evaluation: bladder, stomach, cyst Fetal well-being (4D): normal vs abnormal gestures; evaluation of fetal sleep vs. awakening. Motion: deglutition, respiratory motion, eyelid, limbs and mouth motion, fetal digestive peristaltic motion Fetal neuro-myopathy genetic disease (4D): fetal reactivity/tonicity Fetal biopsy (4D): umbilical blood sampling puncture with precision, amniocentesis, kidney dilatation, uropathy Fetal heart (4D): better correlation between valves, chambers and vessels; volume calculation of heart cavities; atrial and ventricular communication; assessment of valvular function Cord insertion using power-Doppler and 3D References: Williams 23rd Edition, chapter 16 Docs ppt

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