Ob Basic-Ultrasound

DR.
CHARMANE CLAIRE AGCAOILI APRIL 16, 2021
BASIC OBSTETRIC AND GYNECOLOGIC

ULTRASOUND
Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Chito, Marco, Mausisa, Najito, Picones, Villones, Carillo, Galvez, Tan, Utod
DR. CHARMANE CLAIRE AGCAOILI APRIL 16, 2021
NOTES
-

NOTES
-

NOTES
● 2 to <20K cycles: sounds
heard by human

NOTES
● Types of Ultrasound
Machine:
○ Portable and
○ Stand-up machine

NOTES
● Curvilinear: abdominal,
pelvic UTZ
● Linear: transvaginal and
transrectal UTZ

NOTES
● Follow the principle of
ALARA “as low as
reasonably achievable”

NOTES
● 2 Effects of UTZ
○ Thermal:
○ Mechanical:
● Attenuation means it
becomes heat in the
tissues
● Very low: nawawala yung
heat
● Pag mataas ang thermal
mag-stay sa organs

NOTES
● The more dense mas
mabilis ang acoustic speed
● Obstetric UTZ is in soft
tissue

NOTES
● Types
○ B-mode/M-mode
○ Doppler UTZ
● B-mode: Black and white
scan
● M-mode: used for the
heart of the baby
● Doppler UTZ: with color,
3D & 4D UTZ
● Is UTZ safe?
○ 2D is safe as long as
it is needed

NOTES
● ALARA is the principle we
should follow

NOTES
● Fetal Presentation and number
○ It is the identification of the
presentation
● Standard OB UTZ
○ Included in usual pelvic UTZ
● Limited exam
○ For example repeat utz for low
amniotic fluid volume
● Specialized exam
○ Example is the congenital anomaly
scan

NOTES
●

NOTES
● Transabdominal UTZ
○ Used in huge
abdominal masses
because
transvaginal utz can
not see above the
pelvis
●

NOTES
● Before we do a
transvaginal we do first a
transabdominal
● Retroverted means the
fundus is pointed towards
the sacrum
● Anteverted uterus is
pointed towards the
bladder

NOTES
●

NOTES
● Better to use TVS when
looking at the uterus,
ovarian pathology,
adnexal and cul de sac

NOTES
Advantages:
● Mas maganda ang view if
you use TVS
● Less painful than
transabdominal because
of full bladder
Disadvantages:
● Can’t see larger masses

NOTES
● Difference between
transabdominal and TVS
view of a first trimester
TRANSVAGINAL TRANABDOMINAL

Full
Bladder NOTES
● View of a gynecologic UTZ
● Full bladder is needed in
Uterus
transabdominal to better
see the organ

Full
Bladder NOTES
-
Ovaries
Ovaries
Uterus

NOTES
Requests Needed:
● Usually obstetric UTZ
● Established AOG
○ Age of the fetus in weeks during
the request of UTZ based on the
LMP, EDC based on scan
● Reason for scan to know the focus of
UTZ
● Contact number is important to call the
attention of the attending when there
is ectopic pregnancy

NOTES
● Error of margin for AOG goes higher
as you go later in your pregnancy
● Later in pregnancy UTZ is not that
accurate anymore beyond 2 weeks
of pregnancy
● Dating after 22 weeks is suboptimal
○ Means you can’t base your
AOG on UTZ because it’s
already beyond 2 weeks

NOTES
Discrepancy between Menstrual and UTZ EDC
● >5days LMP discrepancy vs <9wks request
for UTZ, you will follow the UTZ bcoz mas
accurate and UTZ
● 2-3 days discrepancy follow LMP
How to compute for AOG?
● LMP: Jan.5, 2021
● Date today: April 16, 2021
● AOG: 14wks 4/7 days
● Computation:
[Jan(31-5)+Feb(28)+March(31)+April(16)]=
101 divided by (7days)
●
NOTES
● Meaning meron ng established age,
she’s sure of her LMP but discrepancy
is more than 3 weeks=> rule out IUGR
● IUGR: Intrauterine Growth Restriction
○ Mas maliit si baby in comparison
with AOG
● Request another UTZ 2-3 wks after to
see if the baby is growing for close
monitoring to avoid intrauterine fetal
demise
●

NOTES
● 1st trimester: 0-14 wks
● 2nd trimester: 15-28wks
● The rest is from 29-42wks

NOTES
●

NOTES
● Nuchal translucency thickness:
yung batok ng baby
What’s the importance?
● One of the measures to see
chromosomal abnormalities
● down syndrome: thickened nuchal
translucency
● There are other congenital
malformations that can develop
later on pregnancy

NOTES
● Hindi lahat kelangan
bigyan ng request for UTZ
unless may complaint ng
hypogastric pain, bleeding,
ART (Artificial
Reproductive Technique),
and not sure of LMP

NOTES
Best time to:
● assess age of baby
● access the nuchal
translucency para
makatipid ang patient
● test for chorionicity
(multiple pregnancy),
developing placenta,
adnexa (ovaries and
fallopian tube)
● assess the cervix

NOTES
● Binasa lang po ni doc*

NOTES
●
Yolk Sac Embryo
Gestational sac without

Embryo
TRANSVAGINAL

NOTES
● Rhombencephalon: unang
nagdedevelop sa fetal brain
Cephalic Caudal end

NOTES
●
Caudal end
Fetal head

NOTES
● In ultrasound Viability is defined as
presence of cardiac activity
● In OB viability is defined as viable
pregnancy usually after 20wks
● In Perinat and neonat: viability is
defined as when a baby is
delivered; will depend also on the
NICU capability of the hospital
● In a book above 20wks or 500g is
the viability

NOTES
● Kapag nagpa UTZ early in the
pregnancy (1st 3 weeks) hindi mo
dapat iexpect na may embryo
agad only a decidualized
endometrium (makapal and
endometrial lining)
● Dapat alam mo yung stages at
kelan sila makikita sa UTZ para
hindi ka magsabi na may
gestational sac pero walang
embryo baka na abort.

NOTES
● Pano masabing hindi na maganda ang pregnancy
● Embryonic bradycardia (<100)
● Don’t tell your patient na iraspa na agad on the
first UTZ kasi pangit ang findings.
● Repeat the UTZ a week or 2 wks after to confirm
this abnormal finding
● An embryo and gestational sac should grow
1mm/day, if hindi nag grow that’s the time you can
say hindi viable ang pregnancy or pregnancy failure
● Pwede din magkamali ang mga sonologist

NOTES
How to measure Pregnancy
Failure
● MSD: Mean Sac Diameter
(gestational sac)
● TAS: Transabdominal Scan
● TVS: Transvaginal Scan
● In TVS mas maliit ang
makikita

NOTES
● CRL: Crown Rump Length -
most precise
measurement in the 1st
trimester
● Accuracy is + 5days
● <3 days discrepancy
follow LMP
● >7 days LMP discrepancy
follow UTZ

NOTES
● Crown: fetal head
Fetal head ● Rump: pwet ng baby
(Crown)
Fetal Nasal Bone
Fetal Brain
Rump
Dito minimeasure ang nuchal

transluscency

NOTES
● HC: Head circumference

NOTES
● Large subchorionic fluid
collection => Subchorionic
hematoma or hemorrhage

NOTES
● What is the most common
pathology with previous CS
● Have high risk for curettage
● To rule out placenta
○ Placenta previa
● Worst placenta previa with uterine
scars: Placenta accreta (abnormally
adherent placenta)
● In the first tirmester always look
for the urinary bladder

NOTES
● Ectopic pregnancy
○ Outside the uterus
○ Extrauterine
pregnancy

Gestational NOTES
Sac ● Gestational sac is noted
outside the uterus
UTERUS ● There’s already a fetus
Embryo and yolk sac
Yolk sac
Left Ectopic Pregnancy

NOTES
● How to diagnose ectopic pregnancy
and differentiate it with an early
intrauterine pregnancy (IUP) in UTZ
● Gestational sac is round in IUP
● Pseudosac or Ectopic: ovoid shape

NOTES
● IUP kasi may double sac
Pseudosac:
● Ovoid
● IUGS: Intrauterine
● Single sac Gestational Sac
(manipis)
● central
IUGS:
● Round
● Double sac
● eccentric

NOTES
● When you see ectopic pregnancy
request for Beta HCG
● Should be serum not urine beta
HCG

NOTES
● Level of B-HCG usually doubles in 2
days
● Pag tiningnan ang b-hcg sa UTZ
mahirap sabihin kung abortion,
ectopic, so request for baseline hcg
● Pag nag doble: intrauterine
(normal)
● Pag bumababa: abortion
● Pag tumataas pero kalahati lang:
suspect ectopic pregnancy

NOTES
● Mid trimester UTZ is the
second trimester UTZ
● Up to 22wks still accurate
in doing your aging

NOTES
● Best time to do mid
trimester scan: between
18-22 weeks
● 24-26 weeks congenital
scan

NOTES
● What to measure during
mid trimester?
○ BPD
○ HC
○ AC
○ FDL

NOTES
●
Fetal head Fetal abdomen
Liver
Femur
Stomach

NOTES
● Estimation of fetal weight
● Table of nomogram
● If you are suspecting IUGR
request UTZ after 2-3wks

NOTES
● Measuring amniotic fluid
● Amniotic fluid is produced
by:
○ Chorion frondosum
○ Skin
○ urine - Major source
of fetal fluid

NOTES
● Amniotic fluid is also produced by
fetal respiratory tract fluid and fetal
swallowing
● No kidneys in UTZ (Renal Agenesis),
what will happen in amniotic fluid?
○ Konti ang amniotic fluid
● No stomach bubble in UTZ:
Amniotic fluid will increase

NOTES
● This is the amnitioc fluid
volume (AFV) we expect
in each AOG

NOTES
● 4 Quadrant: divide the
abdomen into four and
measure the amniotic
fluid in each quadrant
● Single deepest pocket:
look for the deepest area

NOTES
● SVP: Single Vertical Pocket
● AFI: Amniotic Fluid Index
● Normal when using SVP is
2-8cm

NOTES
● Single deepest pocket is
the preferred technique
● Kapag nakakita kayo ng
report from OB sonologist
they only used one pocket
Not 2cm, should be less than 2cm

NOTES
● When doing pelvic UTZ
look for the placenta and
its relationship with the
cervix
Placenta previa ● Placenta Previa:
bumabara yung placenta
sa cervix
Fetal Head/Fetal
presentation

NOTES
● Question: Bakit kelangan ulitin ang UTZ by
35-36wks? Ano ang nangyayari sa uterus?
● Answer: lumalaki ang uterus, naddisplace ang
placenta kasi may nafform na lower uterine
segment.
● Humahaba ang lower uterine segment during TERM,
nasstretch out ang uterus that’s why naddisplace
paakyat ang placenta
● Kapag hindi nadisplace ang placenta, placenta previa
pa din yun.

NOTES
● 3 Classification of Placental
Location
○ Normal
○ Low-lying
○ Previa
● Wala na yung dating classification
na marginalis and totalis

Edge of placenta
NOTES
● Normal placenta more than 2cm
apart
Cervix
● Placenta Previa: nag overlap,
nilampasan na yung internal os
Abdominal UTZ ● Low lying placenta: from the edge
of the placenta to internal os is less
than 2cm

NOTES
● What is the significance of
placental edge, how will you
deliver?
● This is how you will explain to
the patient their type of delivery
● Lahat ng overlapping placenta
previa hindi pwede mag normal
delivery. Schedule for CS at term

NOTES
● Placental doppler uses
color in the assessment
like to rule out placenta
accreta
● Do CS and hysterectomy

NOTES
● Assess for the cervix
● Normal cervical length = >25mm @
16-24wks
● Not routinely done to do a cervical
length measurement
● Cervical assessment uses a
transvaginal probe even if the
abdomen is already big

NOTES
● Multiple gestation
● Chorionicity is better evaluated
before 14-15wks
● Saan nakikita ang lambda sign and
T-sign?

NOTES
● Type of twinning can be assessed
on the day of separation of sac
after fertilization
● For example: if the the sac
separates 1-3 days after
fertilization you will have a
dichorionic, diamnionic type of
twinning

T-sign NOTES
● What type of twinning
would you see the T-sign
and the Lambda sign?
● Di-Di: Lambda sign
● Mono-Di: T-sign
*magulo explanation ni doc, di
Lambda sign ko na-gets sorry:( tiningnan ko na
lang siya sa internet.

NOTES
● How to measure the discordance
○ Wt of larger twin minus wt. of
smaller twin over wt of the
larger twin
● A score of 20% discordance is high
risk for adverse outcome
● Memorize the formula, tinatanong
daw sa ward rotation

NOTES
● How to monitor Multiple
gestation?
● Mono-mono is more complicated
because:
○ They share one placenta
○ Risk for cord entanglement
○ Twin to twin transmission
syndrome
● That’s why mono-mono should
have more frequent UTZ

NOTES
●

NOTES
● This is a detailed examination,
measuring everything from head to
toe for a congenital scan
● Doc is doing scan @ 24 weeks kasi
may mga congenital anomalies na
mas kita later

NOTES
● Diagram of a fetal brain
● Look for the
○ Cerebellum
○ Thalamus
○ Cavum septum
pellucidum

NOTES
● More than 10 madami na
ang fluid in hydrocephalus
● Meningocele may bukol
Lateral
Ventricles

NOTES
● Coronal view of the upper
lip
● All the diagram shows
normal or intact upper lip,
orbit and nasal bone

NOTES
● Fetal upper lip with cleft
using 3D/4D UTZ

Sacrococcygeal
teratoma
NOTES
● Sacrococcygeal teratoma:
mass going out
●
Fetal
spine
MRI

NOTES
● Diagram of fetal long bones

NOTES
● Diagram of a club foot
● Dapat di nakikita yung 5 toes
kasabay nung perpendicular long
bones

NOTES
● Count the number of toes during
congenital scan

NOTES
● Biophysical profile is not part of a
routine exam, request only if
needed

NOTES
● These are the conditions
of a mother to request for
Biophysical Profile Scoring
(BPS) => complicated
pregnancies

NOTES
● Binasa lang po ni doc

NOTES
● 5 Components of BPS
● Alin ang di nammeasure ng UTZ
among those 5 parameters?
○ Fetal heart rate reactivity ->
measured by nonstress test
(NST)
● The rest 4 parameters are UTZ
findings
● Amniotic fluid volume: chronic
parameter (matagal ng may insult)
● Fetal heart reactivity: acute

NOTES
● Scoring of BPS usually
zero or two
● Walang one
● Pag nasa UTZ: over eight
lang
● Pagna NST na that’s the
time you can say over ten

NOTES
● Sabi sa BPS, first to appear last to
disappear
● Tandaan ang mauuna tone,
movement, breathing, reactivity
● Pagmawawala: reactivity,
breathing, movement, tone

NOTES
● If you have patients who are
hypertensive, diabetics request for
OB Doppler velocimetry to measure
arteries
● Bakit ganito ka aga ginagawa?
○ Para makita kung may
preeclampsia si patient or to
prevent IUGR

NOTES
● When a patient comes to you for
fetal aging at 2nd or 3rd trimester
you will base on your non
biometric parameters
● Distal femoral epiphysis present at
32wks
● Placental thickness can be
measured usually compatible at
22-35wks

NOTES
● In gynecologic UTZ you measure
uterine corpus

NOTES
● Uterus is based in relation
to the bladder
Anteverted uterus Retroverted uterus
Midposition uterus

NOTES
● Endometrium depending on the menstrual cycle
● Thickness of endometrium will depend on what day
the ultrasound was requested or the menstrual cycle
● For example if the endometrium is thickened at
proliferative phase (>8mm) it is not normal you
have to manage the patient
● In a bleeding postmenopausal women with >5mm
thickness do biopsy because it is already considered
endometrial cancer

NOTES
● Menstrual phase: Endometrial lining ay
manipis kasi nagsshed-off ang lining
● Proliferative phase: after menses
● Anong hormone ang elevated during
proliferative phase?
○ Estrogen: helps in thickenning your
lining, siya din ang nagpapalaki ng
follicles
● During secretory phase mas mataas na ang
progesterone siya ang nagme-maintain ng
pregnancy

NOTES
● When patient is on tamoxifen it is
expected na may hyperplasia at
cystic spaces sa unang gamit but if
it persists despite discontinuation
do biopsy

NOTES
● Grading of myoma is based on its
attachment to the myometrium
● Also assessed in transvaginal UTZ
<50% Submucous 50% Submucous

myoma myoma
Entirely Submucous
myoma

NOTES
● FIGO Classification
○ PALM
○ COEIN
● Grading of myomas
Intramural myoma
depending on the location
Submucous
○ Submucous
myoma ○ Intramural
○ Subserous
Submserous myoma

NOTES
● Walang nabanggit si doc,
nag jump na sa UTZ

NOTES
● Ovary is seen medial to
iliac vessel
● Normal ovary
Transvaginal UTZ

NOTES
● This is used to determine if
ovarian tumor is malignant or
benign
● Pattern recognition: simple rules
● Green: benign tumors
● Red: malignant tumors

NOTES
● IOTA’s benign and malignant
features

NOTES
● Normal fallopian tubes are not
seen during UTZ
● Hydrosalphinges: fallopian tube
with fluid
● Cog-wheel appearance: nakikita
yung division or incomplete
septation ng fallopian tube
● Salphingitis: inflammation of
fallopian tubes
Fallopian tube with

fluid

NOTES
● Image of a hydrosalpinx: fluid
within the fallopian tube

NOTES
● Hysterogram: done to see the
patency of fallopian tubes
○ for patients who want to get
pregnant
○ Patients with diagnosis of
endometrial polyp
● Papsmear should be normal before
the procedure

NOTES
● Analgesics are given because the
procedure is very painful
● Antibiotics are given especially for
patients with hydrosalpinx

NOTES
● Images show how HSSG/SISH are
done by dilating the uterus
● SISH: Saline Infusion
Sonohysterogram
Polyps

NOTES
● Follicle Monitoring to assess
ovulation
● Look for mature follicle para alam
kelan magsex ang couple

NOTES
● Antral follicle: days 2-4 of your
menses
● Corpus luteum: nagrupture na
mature follicle and nag ovulate
● Mas madalas ang monitoring sa
follicles
Mature follicle
Corpus luteum

NOTES
● Probes being used
○ Abdominal probe
○ Transvaginal probe: mas
malaki
Abdominal probe Transvaginal probe

NOTES
● 2D: black and white
● 3D: may coronal view
● 4D: with color

NOTES
● In 4D the image is real time and
gumagalaw ang baby
● In 3D & 4D UTZ limit to only 30min
kasi heat generating siya hindi
maganda for the baby

NOTES
● A 3D gyne scan
● Difference between normal and
Septate uterus septate uterus (may hati)
●
Normal uterus

NOTES
● Image of a septate uterus and
bicornuate uterus
● In bicornuate uterus bumababa
ang fundus hindi intact

NOTES
● You have to know when to
request an UTZ

NOTES
-


Ob Basic-Ultrasound

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ob Basic-Ultrasound

Uploaded by

Copyright:

Available Formats

DR.

CHARMANE CLAIRE AGCAOILI APRIL 16, 2021

BASIC OBSTETRIC AND GYNECOLOGIC

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Gestational sac without

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Cephalic Caudal end

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Dito minimeasure ang nuchal

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Left Ectopic Pregnancy

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,