Ppds Usg 3. Isuog Basic Obgyn Ultrasound Training Jje 2010

ISUOG Education Committee
BASIC OB/GYN
ULTRASOUND
TRAINING
Judi Januadi Endjun
School of Medicine University of Indonesia – Jakarta

Gatot Soebroto Army Central Hospital
Department of Obstetrics and Gynaecology
2009
MATERI AJAR INI HANYA
UNTUK DIPERGUNAKAN
DALAM KEGIATAN
PENDIDIKAN DAN
KESEHATAN
JJE-2009/11/28 Hanya untuk 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-2009/11/28lebih baik
Hanya untuk Pendidikan dan 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)
INTRODUCTION
 Basic knowledge : embryology, dysmorphology, genetics,
the physiology, and pathophysiology of pregnancy
 Theoretical training
 Practical training
 Residents do not have to accomplish in practice

everything that is being taught in theory

TEXT BOOK REFERENCES
 Judi Januadi Endjun. Ultrasonografi
Dasar Obstetri dan Ginekologi, FKUI,
2009
 Juriy W Wladimiroff, Sturla H Eik-Nes.

European Practice in Gynaecology and
Obstetrics: Ultrasound in Obstetrics and
Gynaecology, Elsevier, 2009
THEORETICAL TRAINING
PROGRAM
 Basic physical principles of medical
ultrasound
 Obstetrics
 Gynecology
 Organization of ultrasound unit
 Medicolegal implications of ultrasound
examination
 Ethics and patient information
Basic physical principles of
medical ultrasound
1. The relevant principles of acoustics, attenuation,
absorbtion, reflection, and speed of sound
2. The effects on tissues of pulsed and continuous

wave ultrasound beams : biological effects, thermal
and non thermal
3. Basic operating principles of medical

instruments :

http://www.cartoonstock.com/newscartoons/cartoonists/sst/lowres/sstn54l.jpg

Basic operating principles of
medical instruments :
a) Pulse echo, scanning principles and 3-D;
b) Pulse echo instruments, including linear

array, curvilinear, mechanical sector,
transvaginal and rectal scanners;
c) Velocity imaging and recording :

Velocity imaging and recording :
 Doppler principles : continuous wave, pulse

wave, color flow mapping, and power Doppler
 Color velocity imaging
 Pitfalls and artifacts

d) Data acquisition
e) Signal processing (may be given in practical

demonstration) :
 Gray scale, time gain compensation, dynamic range,

dynamic focus, digitization, gain compensation,
acoustic output relationship (may be given in
practical demonstration)
f) Artifacts, interpretation and avoidance :

reverberation, side lobes, edge effects,
registration, shadowing, and enhancement
g) Measuring systems : linear, circumference,

area, and volume; Doppler ultrasound : flow,
velocity, spectrum analysis

h) Image recording, storage, and

analysis
i) Interpretation of acoustic output

information and its clinical
relevance
OBSTETRICS
1. Investigation of early pregnancy
2. Assessment of AF and placenta
3. Normal fetal anatomy at 18 – 20 weeks
4. To study the epidemiology, differential

diagnosis, natural history of abnormalities, and
management of structural, functional, and
prognosis and treatment
OBSTETRICS
5. Fetal Biometry
6. Estimation of gestational age
7. Assessment of fetal growth
8. Biophysical scoring systems
9. Evaluation of fetal and uteroplacental
blood flow
10. Knowledge of invasive diagnostic and
therapeutic procedures

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1. Investigation of Early
Pregnancy
a) Ultrasound features of normal early
pregnancy, including GS and YS, simple
and multiple pregnancy, chorionicity
b) Development of fetal anatomy in early

pregnancy including recognition of
abnormalities such as NT, cystic hygroma,
and fetal hydrops
1. Investigation of Early
Pregnancy
c) Embryonic – fetal biometry, e.g. CRL
d) Fetal viability
e) Ultrasound features of early pregnancy
failure including hydatidiform mole
f) Ultrasound and biochemical investigation
of ectopic pregnancy, tumors in early
pregnancy
g) Normal appearance of the cervix
2. Assessment of AF and
Placenta
a) Estimation of AF volume
b) Examination of the placenta
and cord
c) Placental location
d) Number of cord vessels
3. Normal Fetal Anatomy at
18 – 20 Weeks
a) Shape of the skull : nuchal skin fold
b) Facial profile
c) Brain : cerebral ventricles, posterior fossa
and cerebellum, cysterna magna, choroid
plexus cysts (ISUOG guideline)
d) Spine : both longitudinally and
transversely
e) Lungs
3. Normal Fetal Anatomy at
18 – 20 Weeks
f) Heart rate and rhythm, 4-CV, including
atrioventricular valves, outflow tracts (ISUOG
guideline)
g) Shape of the thorax and abdomen
h) Abdomen : stomach, liver, kidneys and urinary bladder,
abdominal wall, and umbilicus
i) Limbs : femur, tibia and fibula, humerus, radius and ulna,
hands and feet – these to include shape, echogenicity of the
long bones and movements
j) Multiple pregnancy : chorionicity
4. To study the epidemiology, differential diagnosis,
natural history of abnormalities, and management of
structural, functional, and prognosis and treatment
a) Structural : skeletal system, CNS, Cardiovascular,

intrathoracic disorder, renal, abdominal wall and
diaphragm, GIT, and markers for chromosomal
abnormalities
b) Functional : polyhydramnios, oligohydramnios,

hydrops, dysrhytmias
c) Prognosis and treatment (including intravascular

therapy)
5. Fetal Biometry
a) Measurements to assess fetal size
(including BPD, HC, AC and FL)
b) Measurements to aid the

diagnosis of fetal anomalies :
anterior/posterior horn of the lateral
ventricle, TCD, and nuchal skinfold (NF)
6. Estimation of Gestational Age
a) Interpretation and appreciation of

limitation of ultrasonic and other
investigations for gestational age
assessment

7. Assessment of Fetal Growth
a) Ultrasonic assessment of fetal

growth : interpretation and
appreciation of limitations of
standard measurement singly or
serially
b) Fetal weight estimation

8. Biophysical Scoring Systems
Interpretation and appreciation of

limitations :
a) Fetal body movements
b) Fetal breathing
c) Heart rate and rhythm

9. Evaluation of Fetal and
Uteroplacental Blood Flow
a) Methodology appropriate to obstetric

investigation
b) Appreciation of problems in blood flow

and velocity measurements and
waveform analysis in normal and
complicated pregnancies
9. Evaluation of Fetal and
Uteroplacental Blood Flow
c) Clinical application and limitations in the
prediction of IUGR and pre-eclampsia
d) Clinical application in monitoring the

small for dates fetus and pregnancies
complicated by Rhesus isoimmunization,
diabetes and fetal cardiac arrhythymias

10. Knowledge of invasive diagnostic
and therapeutic procedures
a) Diagnostic : amniocentesis, CVS,

cordocentesis
b) Therapeutic : shunting and draining

procedures

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GYNAECOLOGY
1. Normal pelvic anatomy

2. Gynecological complications
3. Infertility
4. Invasive procedures
5. Doppler in gynecology

1. Normal Pelvic Anatomy
a. Uterus :
* size, position, shape and measurement
* cyclical morphological changes in the
measurement of endometrial thickness
* endometrium
b. Ovaries

1. Normal Pelvic Anatomy
b) Ovaries :
* size, position, shape & measurement
* cyclical morphological changes
* measurement of follicles and CL
* assessment of peritoneal fluid

2. Gynecological Complications
a) Uterus : fibroids, adenomyosis, endometrial
hyperplasia, endometrial cancer, polyps, location of
IUD
b) Tubes : hydrosalpinx and other abnormalities of the

fallopian tube
c) Ovaries : cysts (benign and malignant,

morphological scoring systems), endometriosis,
ovarian carcinoma, differential diagnosis of pelvic
masses

3. Infertility
a) Monitoring of follicular development in
spontaneous and stimulated cycles
* diagnosis of hyperstimulations
syndrome
* diagnosis of polycystic ovaries
* sonosalpingography

4. Invasive Procedures
a) Oocyte retrieval
b) Injection of ovarian cysts
c) Aspiration of ovarian cysts
d) Drainage of pelvic abscesses
e) Extraction of IUD

5. Doppler in Gynecology
a) Infertility and oncology

Organization of ultrasound unit
Infrastructure
Documentation
Qualitycontrol
Computerization
and Data storage

Medicolegal implications of
ultrasound examination
http://www.mlegal.com/index.2.jpg
Ethics and patient information

http://www.siumed.edu/ethics/Images/medical%20ethics.jpg
PRACTICAL TRAINING
 Required skills
 Certifications

Required Skills
1. Be able to identify early pregnancy and
emergency gynecological problems by
transvaginal and transabdominal ultrasound
2. Be able to recognized the following normal fetal

anatomical features from 18 weeks onwards by
abdominal ultrasound
3. Fetal biometry
4. Activity
Required Skills
1.a. Early pregnancy : fetal viability; description
of the GS, embryo, YS; single and multiple
gestation (chorionicity)
1.b. Pathology : early pregnancy failure; ectopic

pregnancy; gross fetal abnormalities such as NT,
hydropic abnormalities; hydatidiform mole; and
associated pelvic tumors

Required Skills
1.c. Gynecology : normal pelvic anatomy;
uterine size and endometrial thickness;
measurements of ovaries; pelvic tumors, e.g.
fibroids, cysts, hydrosalpinx; peritoneal fluid,
and IUD

Required Skills : normal anatomy
2.a. Shape of the skull; nuchal skinfold
2.b. Brain : ventricles and cerebellum, choroid plexus
2.c. Facial profile
2.d. Spine : both longitudinally and transversely
2.e. Heart rate and rhythm, size and position, 4-CV
2.f. Size and morphology of the lungs

2.g. Shape of the thorax and abdomen

2.h. Abdomen : diaphragm, stomach, liver and
umbilical vein, kidneys, abdominal wall and umbilicus
2.i. Limbs : femur, tibia and fibula, humerus, radius

and ulna, feet and hands – these to include shape,
echogenicity and movement
2.j. Multiple pregnancy : monochorionic and

dichorionic; twin-twin transfusion syndrome

2.k. Amount of amniotic fluid
2.l. Placenta location
2.m. Cord and number of vessels

Fetal Biometry
 CRL
 BPD
 FL
 HC
 AC
 Interpretation of growth charts

Activity :
recognized and quantify
a) Fetal movements
b) Breathing movements
c) Eye movements

CERTIFICATION
1. 100 hours of supervised scanning to
include :
a. 100 gynecological examination and
early pregnancy problems (TVS or
TAS)
b. 200 obstetric scans covering the full
spectrum of obstetrics conditions
1. Logbooks
2. Examination

LOOGBOOKS
30 cases on
one A4 page
with ultrasound
picture – at
least 15
anomalies
should be
included
JJE-2009/11/28
PELA
Hanya untuk Pendidikan dan Kesehatan
EXAMINATION
 MCQ or
 Short written examination paper ( 3 – 4
cases)
 Practical side : transvaginal scan and a fetal
anatomy scan, 30 minutes for both, would be
recommended
 The candidate would take ultrasound
pictures and interpret the images

Ppds Usg 3. Isuog Basic Obgyn Ultrasound Training Jje 2010

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ISUOG Education Committee

Judi Januadi Endjun

School of Medicine University of Indonesia – Jakarta

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

 Residents do not have to accomplish in practice

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

 Juriy W Wladimiroff, Sturla H Eik-Nes.

2. The effects on tissues of pulsed and continuous

3. Basic operating principles of medical

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

a) Pulse echo, scanning principles and 3-D;

b) Pulse echo instruments, including linear

c) Velocity imaging and recording :

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

 Doppler principles : continuous wave, pulse

 Color velocity imaging

 Pitfalls and artifacts

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

e) Signal processing (may be given in practical

 Gray scale, time gain compensation, dynamic range,

f) Artifacts, interpretation and avoidance :

g) Measuring systems : linear, circumference,

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

h) Image recording, storage, and

i) Interpretation of acoustic output

2. Assessment of AF and placenta

3. Normal fetal anatomy at 18 – 20 weeks

4. To study the epidemiology, differential

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

b) Development of fetal anatomy in early

a) Structural : skeletal system, CNS, Cardiovascular,

b) Functional : polyhydramnios, oligohydramnios,

c) Prognosis and treatment (including intravascular

b) Measurements to aid the

a) Interpretation and appreciation of

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

a) Ultrasonic assessment of fetal

b) Fetal weight estimation

Interpretation and appreciation of

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

a) Methodology appropriate to obstetric

b) Appreciation of problems in blood flow

d) Clinical application in monitoring the

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

a) Diagnostic : amniocentesis, CVS,

b) Therapeutic : shunting and draining

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

1. Normal pelvic anatomy

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

b) Tubes : hydrosalpinx and other abnormalities of the

c) Ovaries : cysts (benign and malignant,

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

JJE-2009/11/28 Hanya untuk Pendidikan dan Kesehatan

2. Be able to recognized the following normal fetal